From the Guidelines
The workup for a young patient with stroke should be comprehensive, focusing on identifying both common and uncommon etiologies, and should include immediate neuroimaging, vascular imaging, complete cardiac evaluation, and laboratory testing, as recommended by the 2021 guideline for the prevention of stroke in patients with stroke and transient ischemic attack 1. The initial evaluation should begin with a rapid assessment of airway, breathing, and circulation, followed by a neurological examination to determine focal neurological deficits and assess stroke severity, using a standardized stroke scale such as the National Institutes of Health Stroke Scale (NIHSS) or the Canadian Neurological Scale (CNS) 1. The diagnostic evaluation should include:
- Immediate neuroimaging (CT or MRI) to determine if the stroke is ischemic or hemorrhagic
- Vascular imaging with CT angiography or MR angiography to evaluate for large vessel occlusion, dissection, or vasculopathy
- Complete cardiac evaluation, including electrocardiogram, echocardiogram (transthoracic and possibly transesophageal), and extended cardiac monitoring for at least 24-48 hours to detect paroxysmal atrial fibrillation
- Laboratory testing, including complete blood count, comprehensive metabolic panel, lipid profile, hemoglobin A1c, coagulation studies, and inflammatory markers
- Additional testing for hypercoagulable states, including protein C and S, antithrombin III, factor V Leiden, prothrombin gene mutation, antiphospholipid antibodies, and homocysteine levels, as recommended by the 2021 guideline 1
- Drug screening and testing for vasculitis may be appropriate
- Consider lumbar puncture if CNS vasculitis or infection is suspected
- Genetic testing may be indicated for conditions like CADASIL or Fabry disease if family history suggests inherited disorders. This comprehensive approach is necessary because young stroke patients often have different risk factors than older patients, including arterial dissection, patent foramen ovale, hypercoagulable states, and substance abuse, which require specific management strategies 1.
From the Research
Diagnostic Approach
The diagnostic approach to stroke in young adults involves a multidisciplinary team, including a vascular neurology specialist 2. A "heart to head" diagnostic approach is recommended, starting with a thorough history and physical examination 2.
Initial Testing
Initial testing should include:
- A brain MRI
- Neck and cerebral vascular imaging (e.g., CTA for head and neck)
- Transthoracic echocardiogram with a bubble study
- Telemetry monitoring
- Basic risk factor blood work (e.g., lipid panel, hemoglobin A1c, TSH, ESR, CRP, RPR, HIV, and toxicology screen) 2
Additional Testing
Additional testing may include:
- Blood cultures or a lumbar puncture, with a low threshold to obtain these tests 2
- Sickle screen and pregnancy test, when appropriate 2
Role of Echocardiography
Echocardiography, including transthoracic and transesophageal echocardiography, is a widely used and versatile technique that can provide comprehensive information on thromboembolic risk in patients with stroke 3.
Cardiovascular Imaging
Cardiovascular CT angiography and MRI have growing potential compared with conventional cardiovascular echography 4.
Management
The acute treatment of ischemic stroke in young adult patients does not differ from treatment of older adults, using intravenous alteplase within 4.5 hours, assuming no contraindications 2. Long-term secondary prevention strategies aimed to reduce recurrent stroke risk by targeting and modifying vascular risk factors should be instituted 2.
Risk Factors
Well-established vascular risk factors are prevalent in young stroke patients, and recent studies have informed the treatment of dissection and patent foramen ovale among others 5. The effects of established and emerging risk factors on large and small vessel disease, as well as genetic contributions, should also be considered 6.
Specific Management
Specific management is predicated on identification of the underlying etiology, and a careful history, thorough examination, and methodical workup are essential 5.