From the Guidelines
Multiple cerebral infarcts in young individuals are primarily caused by cardioembolic sources, arterial dissection, hypercoagulable states, vasculitis, illicit drug use, and genetic disorders, with arterial dissections being a relatively common cause, particularly among young patients, as noted in the guidelines for prevention of stroke 1.
Causes of Multiple Cerebral Infarcts in Young Individuals
- Arterial dissections, which can lead to ischemic strokes through artery-to-artery embolism or by causing significant stenosis and occlusion of the proximal vessel 1
- Cardioembolic sources
- Hypercoagulable states
- Vasculitis
- Illicit drug use
- Genetic disorders
Management of Multiple Cerebral Infarcts in Young Individuals
- Rapid neuroimaging (CT or MRI) and vascular imaging to identify the infarcts and their potential causes
- Acute treatment includes intravenous thrombolysis with alteplase (0.9 mg/kg, maximum 90 mg) within 4.5 hours of symptom onset, with 10% given as a bolus and the remainder over 60 minutes
- Endovascular thrombectomy may be considered for large vessel occlusions within 24 hours
- Secondary prevention depends on the underlying cause but typically includes antiplatelet therapy such as aspirin (81-325 mg daily), clopidogrel (75 mg daily), or anticoagulation with direct oral anticoagulants or warfarin if a cardioembolic source is identified 1
- Risk factor modification is essential, including blood pressure control, lipid management with statins, smoking cessation, and diabetes management
- Specific treatments target underlying conditions: immunosuppression for vasculitis, abstinence from illicit drugs, or genetic counseling for inherited disorders
- Comprehensive rehabilitation including physical, occupational, and speech therapy optimizes recovery, with physical activity being particularly important for the prevention of secondary complications related to recurrent stroke and other CVDs 1
- Young stroke patients require thorough investigation of rare causes and long-term follow-up due to their extended life expectancy and risk of recurrence.
From the Research
Causes of Multiple Cerebral Infarcts in Young Individuals
- Autoimmune diseases, such as systemic lupus erythematosus, mixed connective tissue disease, central nervous system vasculitis, and Takayasu arteritis, can cause multiple cerebral infarcts in young individuals 2
- Other causes include hypercoagulability, cardiac embolism, and vasculitis 2
- Arterial dissection and cardioembolism are also common causes of stroke in young adults 3
- A comprehensive etiological workup, including MRI, cardiac investigations, and laboratory tests, is necessary to identify the underlying cause of multiple cerebral infarcts in young individuals 3
Clinical Characteristics and Management
- Patients with multiple cerebral infarcts often present with acute infarction lesions in multiple vascular territories 2
- Clinical characteristics, such as age, sex, and risk factors, can vary depending on the underlying cause of the infarcts 4
- Management of multiple cerebral infarcts in young individuals requires a multidisciplinary approach, including neurologists, cardiologists, and other specialists 3
- Treatment options may include anticoagulation, antiplatelet therapy, and management of underlying conditions, such as autoimmune diseases or cardiac disorders 2, 5
Etiological Workup and Classification
- The etiological workup for cerebral infarction in young adults should include a sequential diagnostic approach, with first-line screening for common causes, such as arterial dissection and cardioembolism 3
- The TOAST and ASCO classification systems can be used to classify the causes of stroke in young adults 4, 5
- A comprehensive etiological workup is necessary to identify the underlying cause of multiple cerebral infarcts in young individuals, as some cases may remain unexplained despite extensive investigations 3, 5