What is the approach to managing stroke in young patients?

Management of Stroke in Young Patients

Young stroke patients should be referred to a comprehensive stroke unit with specialized expertise in evaluating and managing stroke in the young, particularly when no obvious cause can be found, as this approach significantly improves outcomes and reduces mortality.1

Initial Assessment and Management

• Young patients with stroke require urgent comprehensive evaluation, including immediate brain imaging with CT or MRI to differentiate between ischemic and hemorrhagic stroke 1
• Stroke in young patients (under 50 years) has a different etiological spectrum compared to older adults, with 55% being ischemic and 45% hemorrhagic 1
• Initial management should include airway protection, breathing support, and circulatory stabilization, as 61% of pediatric stroke patients require ICU admission and 32% need intubation 2
• Altered mental status at presentation is the strongest predictor for critical care utilization in young stroke patients 2

Diagnostic Workup

• A comprehensive vascular assessment is essential, including full neuroradiology services (CT, MRI with diffusion-weighted imaging, MRA, angiography, and duplex Doppler carotid sonography) 1
• Young stroke patients require more extensive etiological investigations compared to older patients due to different underlying causes 3
• Key investigations should include:
  • Complete hematological profile including clotting studies 1
  • Cardiac evaluation including transthoracic and transesophageal echocardiography to identify cardioembolic sources 1
  • Vascular imaging to identify arteriopathies, which are present in approximately 50% of pediatric stroke cases 3
  • Screening for infectious/parainfectious etiologies, which are among the most common causes of stroke in the young 3

Common Etiologies in Young Stroke Patients

• Arteriopathies (focal cerebral arteriopathy, dissection, Moyamoya disease) 3
• Cardioembolic causes (not associated with atrial fibrillation) 1
• Prothrombotic states and hereditary coagulopathies 3
• Infectious/parainfectious etiologies 3
• Vascular malformations and aneurysms (particularly important in hemorrhagic stroke) 4
• Sickle cell disease in relevant populations 1

Treatment Approaches

Acute Management

• For ischemic stroke:

  • Consider thrombolysis for eligible patients who can reach appropriate facilities within the treatment window 1
  • Anticoagulation with heparin or low molecular weight heparin may be considered, though controversy exists regarding optimal treatment 3
  • Specific protocols for systemic heparin administration in children are available, with adjustments based on age and weight 1

• For hemorrhagic stroke:

  • Neurosurgical evaluation for patients with significant mass effect 1
  • Consider decompressive surgery for malignant middle cerebral artery syndrome or cerebellar hemorrhage with mass effect 1

Secondary Prevention

• Antithrombotic therapy should be tailored based on the underlying etiology:

  • For arterial dissection or cardioembolic sources, anticoagulation may be appropriate 1
  • For other causes, antiplatelet therapy is commonly used 3
  • In children, warfarin dosing should follow age-appropriate protocols 1

• Address modifiable risk factors:

  • Hypertension management (most important modifiable risk factor) 4
  • Treatment of underlying conditions (e.g., cardiac abnormalities, coagulopathies) 1

Rehabilitation and Follow-up

• Comprehensive rehabilitation should begin early and continue through the subacute and chronic phases 5
• Multidisciplinary team approach including neurologists, rehabilitation specialists, physical therapists, occupational therapists, speech therapists, and psychologists 1
• Regular follow-up assessments to monitor for:
  • Neurological deficits (present in 57% of children at discharge) 2
  • Cognitive and behavioral problems (present in the majority of pediatric stroke survivors) 3
  • Recurrent stroke risk (occurs in 10-25% of children with stroke) 1

Specialized Care Settings

• Young stroke patients with no identifiable cause should be managed at level three facilities (comprehensive stroke units) with specialized expertise 1
• These centers should have:
  • Stroke specialists trained in stroke care
  • Full multidisciplinary team
  • Comprehensive laboratory and imaging capabilities
  • Neurosurgical services
  • Focused vascular surgery capabilities
  • Full cardiac services 1

Pitfalls and Caveats

• Delayed diagnosis is common in young stroke patients due to the many mimics and variety of presenting symptoms beyond typical hemiparesis 3
• Stroke in the young can present with atypical symptoms including ataxia, seizures, or altered mental status 3
• Do not assume that young age precludes stroke diagnosis when neurological symptoms are present 1
• The absence of traditional risk factors does not rule out stroke in young patients 4
• Consider telemedicine consultation with specialized centers when direct transfer is not immediately possible 1