ISCHEMIC STROKE / CLASSIFICATION AND ETIOPATHOGENESIS
Stroke in young adults
Created 17/12/2021, last revision 12/05/2023
- young adults stroke = stroke in persons aged 18 to 55 years
- some authors use an upper age limit of 45 or 49 years
- some authors use an upper age limit of 45 or 49 years
- young adults comprise 10%–15% of all stroke patients, with a significant increase after the age of 40 [Smajlović, 2015]
- compared to the older population (where arteriolopathy, atherothrombosis, and cardioembolism due to AFib predominate), the spectrum of risk factors and possible causes are differently distributed and are broader in the younger population [Schöberl, 2017]
- 25% – cardioembolic stroke (valvular defects, cardiac tumors, PFO)
- 20% – arterial dissection
- 10% – rare causes (vasculitis, vasculopathies, thrombophilia, genetic diseases, etc. )
- 25-50% – cryptogenic stroke (of which 20-30% meet ESUS criteria)
- ?% – stroke in pregnancy and puerperium
- approximately from the age of 40, the proportion of vascular risk factors increases, together with the proportion of large and small vessel disease (TOAST 1 and 3)
- a thorough etiologic diagnostic evaluation and individualized secondary prevention are essential
- the acute treatment is the same for patients of all ages ( recanalization therapy if eligible)
Etiology and risk factors
- the identification of rare causes of juvenile stroke requires a significant diagnostic effort
- the most common etiology of stroke in young adults is a cryptogenic stroke (20-40%) and cardioembolic stroke
[Smajlović, 2015]
- TOAST classification may overestimate patients with stroke of undetermined etiology (TOAST 5), mainly because patients with two or more potential etiologies fall into this group
- in young patients with carotid artery occlusion or stenosis, exclude dissection and vasculitis
- modifiable vascular risk factors are similar for younger and older patients
- hypertension, heart disease (including atrial fibrillation), dyslipidemia, and diabetes mellitus are the most common risk factors among the elderly
- in young stroke patients, the most common vascular risk factors are dyslipidemia, smoking, and hypertension [Putaala, 2012]
- patients without documented risk factors have less frequent recurrent ischemic strokes and non-cerebrovascular arterial events
DDx in young stroke patients using the TOAST classification |
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Large-Artery Atherosclerosis (TOAST 1) | |
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Cardioembolism (TOAST 2) → cardioembolic stroke |
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Small artery disease (TOAST 3) | |
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Stroke of other determined etiology (TOAST 4) | |
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Cryptogenic stroke (TOAST 5) → see here |
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In addition to the TOAST classification, stroke in pregnancy and puerperium of various etiopathogenesis must be mentioned |