Trigger factors in patients with a patent foramen ovale-associated stroke: A case-crossover study

BACKGROUND

Patent foramen ovale (PFO) is a congenital anatomical variant which is associated with strokes in young adults. Contrary to vascular risk factors and atherosclerosis, a PFO is present from birth. However, it is completely unknown how an anatomical structure that is already present at birth in a large proportion of the population can convert into a PFO that causes stroke in a few. Recent studies reported a significant association between certain trigger factors and ischemic stroke in young adults. This study aims to investigate these triggers in PFO-associated stroke.

METHODS

The ODYSSEY study, a multicenter prospective cohort study between 2013 and 2021, included patients aged 18-49 years experiencing their first-ever ischemic event. Participants completed a questionnaire about exposure to potential trigger factors. A case-crossover design was used to assess the relative risks (RR) with 95% confidence intervals (95% CI). The primary outcome was the RR of potential trigger factors for PFO-associated stroke.

RESULTS

Overall, 1043 patients completed the questionnaire and had an ischemic stroke, of which 124 patients had a PFO-associated stroke (median age 42.1 years, 45.2% men). For patients with PFO-associated stroke, the RR was 26.0 (95% CI 8.0-128.2) for fever, 24.2 (95% CI 8.5-68.7) for flu-like disease, and 3.31 (95% CI 2.2-5.1) for vigorous exercise.

CONCLUSION

In conclusion, flu-like disease, fever, and vigorous exercise may convert an asymptomatic PFO into a stroke-causing PFO in young adults.

DATA ACCESS STATEMENT

The raw and anonymized data used in this study can be made available to other researchers on request. Written proposals can be addressed to the corresponding author and will be assessed by the ODYSSEY investigators for appropriateness of use, and a data sharing agreement in accordance with Dutch regulations will be put in place before data are shared.

Evaluating the risk of ischemic stroke at a young age in patients with autoimmune inflammatory rheumatic diseases: a population-based cohort study in Taiwan

Background

Recent studies have demonstrated an increased incidence of ischemic stroke among patients with certain autoimmune inflammatory rheumatic diseases (AIIRDs). However, the associations between young stroke and AIIRDs have not been fully investigated. This study aimed to evaluate the risk of ischemic stroke among young patients with AIIRDs.

Methods

The National Health Insurance Research Database in Taiwan was utilized to establish cohorts of patients with AIIRDs diagnosed between 2004 and 2015, who were compared with 1,000,000 control participants. Cox proportional hazards regression models were used to calculate the hazard ratio of ischemic stroke and young ischemic stroke for individual AIIRDs after adjustment for relative risk factors.

Results

During the study period, a total of 64,120 patients with AIIRDss and 1,000,000 control patients were identified. The overall mean follow-up time was 5.33 years. There were 223 (0.8%) and 1,923 (0.3%) young ischemic stroke-related hospitalizations among patients with AIIRDs and controls, respectively. The incidence rate of young ischemic stroke was 0.08 in patients with rheumatoid arthritis, 0.08 in patients with Sjögren's syndrome, 0.26 in patients with systemic lupus erythematosus, 0.17 in patients with idiopathic inflammatory myositis, 0.24 in patients with systemic sclerosis, 0.05 in patients with Behçet's disease, and 0.44 in patients with systemic vasculitis, versus 0.05 per 100 person-years in the general population. The adjusted hazard ratios for young ischemic stroke were 1.07 (95% CI 0.70-1.43) for rheumatoid arthritis, 1.39 (95% CI 0.94-2.06) for Sjögren's syndrome, 5.79 (95% CI 4.68-7.17) for systemic lupus erythematosus, 2.07 for idiopathic inflammatory myositis (95% CI 0.98-4.38), 2.79 for systemic sclerosis (95% CI 1.38-5.63), 0.82 for Behçet's disease (95% CI 0.26-2.55), and 4.15 (95% CI 1.96-8.82) for systemic vasculitis.

Conclusions

Patients younger than 50 years with systemic lupus erythematosus, systemic sclerosis, or systemic vasculitis have a significantly elevated risk of developing ischemic stroke. Further research is needed to elucidate the pathogenesis of accelerated atherosclerosis in these AIIRDs.

Neurological phenotype of adenosine deaminase 2 deficient patients: a cohort study

BACKGROUND AND PURPOSE

Patients with adenosine deaminase 2 (ADA2) deficiency can present with various neurological manifestations due to vasculopathies and autoinflammation. These include ischaemic and hemorrhagic stroke, but less clearly defined neurological symptoms have also been reported.

METHODS

In this cohort study, patients with confirmed ADA2 deficiency from seven university hospitals in the Netherlands were included. The frequency and recurrence rates of neurological manifestations before and after initiation of tumor necrosis factor α (TNF-α) inhibiting therapy were analyzed.

RESULTS

Twenty-nine patients were included with a median age at presentation of 5 years (interquartile range 1-17). Neurological manifestations occurred in 19/29 (66%) patients and were the presenting symptom in 9/29 (31%) patients. Transient ischaemic attack (TIA)/ischaemic stroke occurred in 12/29 (41%) patients and was the presenting symptom in 8/29 (28%) patients. In total, 25 TIAs/ischaemic strokes occurred in 12 patients, one after initiation of TNF-α inhibiting therapy and one whilst switching between TNF-α inhibitors. None was large-vessel occlusion stroke. Two hemorrhagic strokes occurred: one aneurysmatic subarachnoid hemorrhage and one spontaneous intracerebral hemorrhage. Most neurological symptoms, including cranial nerve deficits, vertigo, ataxia and seizures, were caused by TIAs/ischaemic strokes and seldom recurred after initiation of TNF-α inhibiting therapy.

CONCLUSIONS

Neurological manifestations, especially TIA/ischaemic stroke, are common in patients with ADA2 deficiency and frequently are the presenting symptom. Because it is a treatable cause of young stroke, for which antiplatelet and anticoagulant therapy are considered contraindicated, awareness amongst neurologists and pediatricians is important. Screening for ADA2 deficiency in young patients with small-vessel ischaemic stroke without an identified cause should be considered.

Obesity-hyperlipidemia, Hypertension, and Left Atrial Enlargement During Stroke in Young Adults

BACKGROUND

This study investigated the association between left atrial enlargement and stroke severity in young adults. We also studied the differences between the normal and left atrial enlargement groups in clinical data.

METHODS

A total of 135 young stroke patients admitted to the Department of Neurology of the Taizhou People's Hospital were recruited from January 2018 to December 2021. The patients were divided into normal and enlarged groups by left atrial size. The relationship between the left atrial diameter and the National Institutes of Health Stroke Scale score was analyzed apart from the differences in clinical variables.

RESULTS

No relationship was observed between the left atrial diameter and the National Institutes of Health Stroke Scale score ( r =-0.045 P =0.603). The univariate analysis of both groups revealed that hypertension ( P =0.004), hyperlipidemia ( P =0.001), body mass index ( P =0.000), obesity ( P =0.015), and not stroke etiologic subtypes were associated with left atrial enlargement. In binary logistic regression analysis models, hyperlipidemia 3.384 (95% CI, 1.536 to 7.452), hypertension 2.661 (95% CI, 1.066 to 6.639), and obesity 2.858 (95% CI, 1.158 to 7.052) were significantly associated with the young stroke of left atrial enlargement.

CONCLUSIONS

In young adults, obesity-hyperlipidemia and hypertension were significantly associated with left atrial enlargement in stroke.

Functional brain connectivity in young adults with post-stroke epilepsy

Approximately 1 in 10 young stroke patients (18-50 years) will develop post-stroke epilepsy, which is associated with cognitive impairment. While previous studies have shown altered brain connectivity in patients with epilepsy, little is however known about the changes in functional brain connectivity in young stroke patients with post-stroke epilepsy and their relationship with cognitive impairment. Therefore, we aimed to investigate whether young ischaemic stroke patients have altered functional networks and whether this alteration is related to cognitive impairment. We included 164 participants with a first-ever cerebral infarction at young age (18-50 years), along with 77 age- and sex-matched controls, from the Follow-Up of Transient Ischemic Attack and Stroke patients and Unelucidated Risk Factor Evaluation study. All participants underwent neuropsychological testing and resting-state functional MRI to generate functional connectivity networks. At follow-up (10.5 years after the index event), 23 participants developed post-stroke epilepsy. Graph theoretical analysis revealed functional network reorganization in participants with post-stroke epilepsy, in whom a weaker (i.e. network strength), less-integrated (i.e. global efficiency) and less-segregated (i.e. clustering coefficient and local efficiency) functional network was observed compared with the participants without post-stroke epilepsy group and the controls (P < 0.05). Regional analysis showed a trend towards decreased clustering coefficient, local efficiency and nodal efficiency in contralesional brain regions, including the caudal anterior cingulate cortex, posterior cingulate cortex, precuneus, superior frontal gyrus and insula in participants with post-stroke epilepsy compared with those without post-stroke epilepsy. Furthermore, participants with post-stroke epilepsy more often had impairment in the processing speed domain than the group without post-stroke epilepsy, in whom the network properties of the precuneus were positively associated with processing speed performance. Our findings suggest that post-stroke epilepsy is associated with functional reorganization of the brain network after stroke that is characterized by a weaker, less-integrated and less-segregated brain network in young ischaemic stroke patients compared with patients without post-stroke epilepsy. The contralesional brain regions, which are mostly considered as hub regions, might be particularly involved in the altered functional network and may contribute to cognitive impairment in post-stroke epilepsy patients. Overall, our findings provide additional evidence for a potential role of disrupted functional network as underlying pathophysiological mechanism for cognitive impairment in patients with post-stroke epilepsy.

Long-term risk of recurrent vascular events and mortality in young stroke patients: Insights from a multicenter study

BACKGROUND

Although the incidence of stroke in the young is rising, data on long-term outcomes in these patients are scarce. We thus aimed to investigate the long-term risk of recurrent vascular events and mortality in a multicenter study.

METHODS

We followed 396 consecutive patients aged 18-55 years with ischemic stroke (IS) or transient ischemic attack (TIA) enrolled in three European centers during the period 2007-2010. A detailed outpatient clinical follow-up assessment was performed between 2018 and 2020. When an in-person follow-up visit was not possible, outcome events were assessed using electronic records and registry data.

RESULTS

During a median follow-up of 11.8 (IQR 10.4-12.7) years, 89 (22.5%) patients experienced any recurrent vascular event, 62 (15.7%) had any cerebrovascular event, 34 (8.6%) had other vascular events, and 27 (6.8%) patients died. Cumulative 10-year incidence rate per 1000 person-years was 21.6 (95% CI 17.1-26.9) for any recurrent vascular event and 14.9 (95% CI 11.3-19.3) for any cerebrovascular event. The prevalence of cardiovascular risk factors increased over time, and 22 (13.5%) patients lacked any secondary preventive medication at the in-person follow-up. After adjustment for demographics and comorbidities, atrial fibrillation at baseline was found to be significantly associated with recurrent vascular events.

CONCLUSIONS

This multicenter study shows a considerable risk of recurrent vascular events in young IS and TIA patients. Further studies should investigate whether detailed individual risk assessment, modern secondary preventive strategies, and better patient adherence may reduce recurrence risk.

Exploring the Unmet Needs of Young Adults with Stroke in Australia: Can Technology Help Meet Their Needs? A Qualitative Study

The post-stroke needs of young adults with stroke are not being met, as most resources are tailored to older people with stroke. This includes technology-based applications, which are being used more frequently in stroke rehabilitation. There is limited data on technology usage to support the unique needs of young adults with stroke in Australia. This study aimed to explore the unmet needs of young adults aged 18-30 years with stroke and ascertain how technology can help meet those needs to improve quality of life and participation. Sixteen in-depth semi-structured interviews were conducted with young adults with stroke (n = 10), healthcare professionals (n = 3) and caregivers of young adults with stroke (n = 3). The interviews were transcribed verbatim and analyzed inductively. Five themes were generated: 'Support for recovery', 'Availability of specific resources', 'Continuity of care', 'Adjustment' and 'Knowledge'. This study revealed the unique needs of young adults under 30 years with stroke who requested more targeted post-stroke support, age-specific resources and improved awareness on young stroke, with technology playing a pivotal role in all these interventions. We suggest co-designing technology-based solutions with young people after stroke to maximize their effectiveness in improving quality of life and participation in this unique cohort.

Predictors of favorable outcome and mortality after endovascular thrombectomy in young Chinese patients with large vascular occlusions

Background

Endovascular thrombectomy (EVT) has evolved into the standard treatment for patients with acute ischemic stroke (AIS) and large vessel occlusion (LVO). However, little information is available on the management of EVT in young patients with AIS-LVO in China. The purpose of this study was to assess the favorable outcomes and mortality rates after 90 days of EVT in young Chinese patients with AIS-LVO and their predictors.

Methods

This retrospective study included young Chinese patients aged 18-50 years with AIS-LVO. The primary efficacy endpoint was the modified Rankin scale (mRS) score at day 90, and the primary safety endpoint was mortality within 90 days. Using univariate and multivariate logistic regression analyses, the associations between clinical, imaging, and procedure variables and favorable (mRS 0-2) outcomes or mortality at 90 days were analyzed.

Results

A total of 113 patients were included in the study with a mean age of 43.1 ± 6.3 years. Symptomatic intracranial hemorrhage (sICH) occurred in 8 (7.1%) patients. Favorable functional outcomes (mRS 0-2) were recovered in 42.5% of patients at 3 months. After 90 days, the mortality rate was 32.3%. Multivariate analysis revealed that the increase in admission NIHSS score was associated with a lower probability of functional independence (aOR 1.08, 95% CI 1.02-1.15, p = 0.01 and aOR 1.01, 95% CI 1-1.01, p = 0.008, respectively) and a higher probability of death at 90 days (aOR 1.1, 95% CI 1.03-1.18, p = 0.007 and aOR 1.00, 95% CI 1-1.01, p = 0.021, respectively).

Conclusion

This study demonstrate that EVT provides higher rates of arterial recanalization, rather than better favorable outcomes and lower risk of death at 3 months in young Chinese patients with AIS-LVO. Increased NIHSS scores on admission may be associated with poor patient prognosis.

Comparison Between First-Ever Ischemic Stroke in Young Adults in 1988-1997 and 2008-2017

Aim

To compare incidence of first-ever acute cerebral infarction, etiology and traditional risk factors in young adults 15-49 years in 1988-1997 and 2008-2017 in Hordaland County, Norway.

Methods

Case-finding of young adults with acute cerebral infarction in 1988-1997 was done retrospectively by computer research from hospital registries in Hordaland County. Young adults with acute cerebral infarction living in the Bergen region in 2008-2017 were prospectively included in a database at Haukeland University Hospital. Traditional risk factors, etiology and modified Rankin scale score on discharge were registered.

Results

Crude average incidence of acute cerebral infarction was 11.4 per 100.000 per year in 1988-1997 and 13.2 per 100.000 per year in 2008-2017 (P=0.04). The prevalence of prior myocardial infarction, angina pectoris, and dyslipidemia were lower in the 2008-2017 cohort (all P<0.05). Atherosclerosis was less common in the 2008-2017 cohort (P<0.001).

Conclusion

The observed incidence of acute cerebral infarction in young adults increased from 1988-1997 to 2008-2017 in Hordaland County. Atherosclerosis was less common in the 2008-2017 cohort.

[Ischemic stroke associated with patent foramen ovale: hospital database analysis]

OBJECTIVE

To analyze clinical and instrumental characteristics of patients with ischemic stroke (IS) due to paradoxical embolism according to the data of hospital registers of Moscow and Perm.

MATERIAL AND METHODS

A comprehensive study of 114 patients, aged 18 to 55 years, with IS by the mechanism of paradoxical embolism was carried out. All patients underwent clarification of the cause of IS (electrocardiography, ultrasound scanning of the brachiocephalic arteries, CT or MRI of the brain, CT or MR angiography, transthoracic and/or transesophageal echocardiography). The presence of right-left shunt blood flow (RLS) was confirmed by transcranial dopplerography with a bubble test. The clinical significance of patent foramen ovale (PFO) was assessed according to The PFO-Associated Stroke Causal Likelihood Classification System (PASCAL).

RESULTS

Clinical and instrumental characteristics of patients with IS due to paradoxical embolism were obtained from two hospital registries. In both groups, the leading trigger for the development of IS was the Valsalva phenomen (>20%), the share of other provoking factors did not exceed 10%. Significant differences between the analyzed groups related to the ultrasonic characteristics of RLS/PFO: patients with a grade 4 shunt predominated in the Research Center of Neurology (RCN) population, while patients with a grade 3 shunt predominated in the City Clinical Hospital (CCH) №4 group. At the same time, there were twice as many patients with aneurysm of the interatrial septum in the CCH №4 group. In accordance with the PASCAL classification, in 93% of RCN patients, PFO can be considered as a probable cause of IS, while in the CCH No. 4 group, a probable causal relationship was traced only in 51% of cases, in 18% of patients, the role of an anomaly in the development of stroke was unlikely.

CONCLUSION

The analysis showed that the primary screening of RLS in a regional vascular center allows classifying PFO as a probable cause of IS in only half of the patients. For a more accurate selection of patients for whom endovascular occlusion of the PFO will be most effective, an in-depth examination in a specialized hospital is recommended.

Association between the C-reactive protein to albumin ratio and adverse clinical prognosis in patients with young stroke

BACKGROUND

The inflammatory response plays an important role in ischemic stroke, and the incidence of stroke in young adults has increased rapidly in recent years. The C-reactive protein-to-albumin ratio (CAR) is a new index that reflects the overall inflammatory status of patients with major diseases; however, no studies have reported the relationship between CAR and young stroke.

METHODS

The participants' baseline characteristics and laboratory examination results, including CAR, were obtained at admission. The modified Rankin Scale (mRS) scores at the 30-day and 90-day follow-ups were obtained from all patients. All the participants included in the study were classified into four groups according to CAR quartiles (Q1-Q4). Logistic regression was used to analyze the relationship between different CAR levels and adverse outcomes (mRS 3-6 and mRS 2-6). We also plotted receiver operating characteristic curves of CAR for adverse clinical outcomes and calculated the area under the curve and cutoff values.

RESULTS

A total of 630 patients with young stroke were enrolled in the study. In the multivariate logistic regression model, at the 30-day follow-up, the Q3 and Q4 (significantly increased CAR) groups showed an elevated risk of mRS score of 2-6 (odds ratio [OR]: 2.94; 95% confidence interval [CI]: 1.40-6.16, p < 0.01; OR: 4.01; 95% CI: 1.88-8.91, p < 0.01). At the 90-day follow-up, the Q3 and Q4 groups still showed an elevated risk of an mRS score of 2-6 (Q3, OR: 2.76; 95% CI: 1.30-5.86, p < 0.01; Q4, OR: 2.63; 95% CI: 1.22-5.65, p < 0.01).

CONCLUSION

A significantly increased CAR was independently associated with an increased risk of adverse outcomes in young patients with stroke.

Self-evaluation of personal needs by community-living young stroke survivors using an online English language questionnaire

BACKGROUND

Identifying personal needs of young stroke survivors is crucial for their recovery.

PURPOSE

Identify factors, burden, and significance of unmet needs of young community-living stroke survivors.

MATERIALS AND METHODS

We used online advertising and word-of-mouth snowballing to recruit participants for an English language online questionnaire constructed for this purpose. Eligible participants aged 18-55 at time of stroke. Needs were classified into seven domains: Healthcare Experience, Impairments from Stroke, Everyday Activities, Work/Study, Finances, Relationships, and Social Participation. Random-effects logistic regression was used to determine the probability of unmet needs and X² test to determine significance of distribution across domains.

RESULTS

Out of 137 responses recorded: 32 did not meet inclusion criteria, 29 duplicates identified were discarded, and 76 eligible participants were analysed. Respondents were median 37 (IQR 32-47) years at time of stroke, and median 3 (1-5) years since stroke. Fifty-eight (76%) females. Modified Rankin Scale median score of 1 (1-3). Of 48 identified potential needs, 25 (IQR 19-30) were rated unmet. Twenty (IQR 15-25) considered of high significance. Unmet needs most frequently occurred in the domains: Impairments from Stroke, Finances, and Social Participation.

CONCLUSIONS

There is high burden of unmet needs in community-living young stroke survivors which are spread disproportionately across the identified domains.IMPLICATIONS FOR REHABILITATIONIdentifying personal needs of young stroke survivors is crucial for their recovery.Impairments after Stroke, Finances, and Social Participation were often selected as being high burden unmet needs for community-living young people after stroke.Employing a post-stroke checklist to guide exploration of needs in young stroke may better capture which needs are unmet.

Comparison of Long-Term Outcomes and Associated Factors between Younger and Older Rural Ischemic Stroke Patients

Introduction: The rise of ischemic stroke among young adults has stressed the need to understand their risk profiles and outcomes better. This study aimed to examine the five-year ischemic stroke recurrence and survival probability among young patients in rural Pennsylvania. Methods: This retrospective cohort study included first-time ischemic stroke patients from the Geisinger Health System between September 2003 and May 2014. The outcomes included all-cause mortality and ischemic stroke recurrence at five years. Kaplan-Meier estimator, cumulative incidence function, Cox proportional hazards model, and Cause-specific hazard model were used to examine the association of independent variables with the outcomes. Results: A total of 4459 first-time ischemic stroke patients were included in the study, with 664 (14.9%) patients in the 18−55 age group and 3795 (85.1%) patients in the >55 age group. In the 18−55 age group, the five-year survival probability was 87.2%, and the cumulative incidence of recurrence was 8%. Patients in the 18−55 age group had significantly lower hazard for all-cause mortality (HR = 0.37, 95% CI 0.29−0.46, p < 0.001), and non-significant hazard for five-year recurrence (HR = 0.81, 95% CI 0.58−1.12, p = 0.193) compared to the >55 age group. Chronic kidney disease was found to be associated with increased mortality in the 18−55 age group. Conclusion: In our rural population, younger ischemic stroke patients were at the same risk of long-term ischemic stroke recurrence as the older ischemic stroke patients. Identifying the factors and optimizing adequate long-term secondary prevention may reduce the risk of poor outcomes among younger ischemic stroke patients.

Successful Thrombectomy for Endocarditis-Related Stroke in a Very Young Patient: Illustrative Case

Objective

Unlike in older adults, ischemic stroke in young patients occurs secondary to preexisting conditions. Infective endocarditis (IE) is among the most important causes of stroke in young adults and has a severe prognosis. There are few reports of mechanical thrombectomy (MT) for IE-induced large-vessel occlusion (LVO). This paper reports a case of acute IE-induced LVO in a young patient who was successfully treated with MT.

Case Presentation

An 18-year-old woman presented to our hospital with severe headache, high fever, and left fingertip pain. She was admitted to the Department of Neurology for conservative treatment of suspected meningitis. On day 2 of admission, she developed acute left hemiparesis, left hemispatial neglect, and dysarthria. MRA showed occlusion of the right M1 segment of the middle cerebral artery, and the patient immediately underwent MT. After a single pass, we achieved thrombolysis in cerebral infarction 2b. A white clot was diagnosed as a vegetation on pathological examination. As transesophageal echocardiography showed a vegetation on the mitral valve, the patient was diagnosed with IE and underwent cardiovascular surgery. The patient recovered well and underwent additional treatment and rehabilitation.

Conclusion

Although rare, IE-induced septic emboli may occur in young patients with LVO, necessitating MT and pathological diagnosis of the clot.

Estonian young stroke registry: High burden of risk factors and high prevalence of cardiomebolic and large-artery stroke

Background and aims

The aim of the present study was to assess the risk factor burden and stroke etiology of young stroke patients in Estonia and to compare the results with similar cohorts from other countries.

Methods

This study includes ischemic stroke patients aged 18-54 years from the prospective Estonian Young Stroke Registry between 2013 and 2020. All patients were managed in a stroke unit following a prespecified detailed protocol. Data on stroke risk factors, etiology, and stroke severity were analyzed.

Results

A total of 437 patients (mean age 44.7 ± 8.3 years; 62% males) were included in the registry during the 8-year study period. A total of 50.2% of patients had ≥ 3 well-documented risk factors (higher for men: odds ratio (OR) 3.8; 95% cardiac index confidence interval (CI) 1.8-8.3; p < .001) and 6.2% of patients had ≥ 3 less well-documented risk factors. While 42% of patients had undetermined cause of stroke (34% of them cryptogenic), the second most frequent etiologies were large-artery atherosclerosis and cardioembolism (both 19%). 60 percent of cardioembolic strokes were due to high-risk causes. Large-artery atherosclerosis was more prevalent in men (OR 1.8; 95% CI 1-3.3; p = .05) and among older patients (OR 6.2; 95% CI 1.8-21.4; p = .008). The median National Institutes of Health Stroke Scale score on admission was 3 (interquartile ranges 2-6), stroke was more severe in men (p = .05).

Conclusions

Our study revealed that young patients with stroke in Estonia have higher burden of well-documented risk factors, higher prevalence of high-risk cardioembolic causes and higher prevalence of large-artery stroke compared to other young stroke cohorts.

Development and initial validation of a patient-centered stroke outcome measure in young stroke survivors

BACKGROUND AND PURPOSE

This study was undertaken to develop a patient-centered stroke outcome measure and initial validation of the proposed Young Stroke Questionnaire (YSQ).

METHODS

This study assessed the reliability and discriminant validity of the YSQ. The initial questionnaire evolved from a focus group comprised of six young stroke survivors and six stroke neurologists centralized around four patient-centered domains. To determine the reliability and discriminant validity of the YSQ, 100 young stroke survivors were recruited and provided consent. Standardized clinical assessments completed included the modified Rankin Scale (mRS), National Institutes of Health Stroke Scale, and Stroke Impact Scale. Additionally, all patients were asked to complete the patient-centered YSQ.

RESULTS

Of the 100 enrolled patients in the study (mean age ± standard deviation = 49 ± 11.3, 58% females, 53% African American, 44% White), Cronbach alpha for all domains was >0.7. Moreover, Cronbach alpha for entire questionnaire was >0.9, indicating that the scale, with four subdomains, is internally consistent and reproducible. Discriminant validity of the scale was assessed by comparing the means of each subdomain of the YSQ among healthy subjects to the groups of stroke patients as defined by the mRS. The YSQ was able to differentiate subjects with good outcome (mRS = 0-1) from subjects with varying degree of disability as defined by the mRS (p = 0.026).

CONCLUSIONS

Standardized clinical assessments are not sensitive to disabilities in young stroke survivors. When compared to standardized clinical assessments, the YSQ is significantly capable of differentiating the young survivor perspective of the impact of stroke in all four subdomains.

Feasibility of training using full immersion virtual reality video game in young stroke survivor: A case report

BACKGROUND

With the recent developments in science, full-immersion virtual reality devices have been developed, which may have feasibility for stroke rehabilitation.

OBJECTIVE

This case report investigated the feasibility of training using a full-immersion virtual reality video game for improving motor function, balance, and gait in a young stroke survivor.

METHOD

The case was a 27-year-old woman with stroke. A training using full-immersion virtual reality video game (Sony PlayStation®VR) was performed for 30 minutes per session, 3 sessions per week, for 6 weeks, with a total of 18 sessions. Before training and at each training for 6 weeks, with a total of 19 times, the motor function, balance, and gait were assessed using the Motor Assessment Scale (MAS), Berg Balance Scale (BBS), Timed Up and Go (TUG) Test, and Tinetti Balance Assessment, 10 Meter Walk Test (10MWT), Tinetti Gait Assessment, and Dynamic Gait Index (DGI).

RESULTS

During the training, there were no adverse events reported. The case achieved 14 points higher than the pre-assessment with 34 points on the MAS, 16 points higher than the pre-assessment with 48 points on BBS, 6.85 sec lower than the pre-assessment, with 13.58 sec on TUG, 5 points higher than the pre-assessment with 13 points on the Tinetti Balance Assessment, 5.36 sec lower than the pre-assessment, with 8.15 sec on the 10MWT, 4 points higher than the pre-assessment with 10 points on the Tinetti Gait Assessment, and 10 points higher than the pre-assessment with 21 points on the DGI.

CONCLUSION

This case report suggests that training using a full-immersion virtual reality video game may be a safe and effective method to improve motor function, balance, and gait in a young stroke survivor.

Screening for Fabry Disease in Young Strokes in the Australian Stroke Clinical Registry (AuSCR)

Introduction: Fabry disease (FD) is an X-linked lysosomal storage disorder characterized by a deficiency or absence of alpha-galactosidase A (α-GAL A) enzyme, where stroke can be a serious complication. The aim of this study is to determine the feasibility of centralized screening for FD, among young stroke adults registered in the national Australian Stroke Clinical Registry (AuSCR).

Methods: The study was conducted in young (age 18 – 55 years) survivors of acute stroke of unknown etiology registered in AuSCR at hospitals in Queensland, Tasmania, New South Wales, and Victoria during 2014 – 2015; and who, at the 3-month outcome assessment, agreed to be re-contacted for future research. Descriptive analyses of case identification from responses and specific enzyme and DNA sequencing analyses were conducted for α-galactosidase A (α-GLA) from dried blood spot (DBS) testing.

Results: Of 326 AuSCR-identified patients invited to participate, 58 (18%) provided consent but six were subsequently unable to provide a blood sample and two later withdrew consent to use their data. Among the remaining 50 participants (median age 53 years [48 – 56 years]; 47% female), 67% had experienced an acute ischemic stroke. All males (n = 27) had an initial screen for α-GLA enzyme activity of whom seven with low enzyme levels had normal secondary α-GLA gene analysis. All females (n = 23) had genetic analysis, with one shown to have a pathogenic c.352C>T p.(Arg118Cys) missense mutation of the α-GLA gene for FD.

Conclusions: These findings provide logistical data for embedding a process of automated central stroke registry screening for an additional case-finding tool in FD.

[Pulmonary arteriovenous shunt - a rare cause of recurrent stroke due to paradoxical embolism]

Paradoxical embolism is one of the mechanisms of ischemic stroke in patients younger than 45 years of age, due to opening between the right and left chambers of the heart through a patent foramen ovale, an atrial or ventricular septal defect, pulmonary arteriovenous malformations (PAVMs), etc. The PAVMs are structurally abnormal vessels that provide direct capillary-free communication between the pulmonary and systemic circulations, and hence an anatomic "right-to-left" shunt. Most pulmonary malformations are congenital and associated with hereditary hemorrhagic telangiectasia (Rendu-Osler-Weber disease). This publication highlights the issues of pathogenesis, clinical presentation, diagnosis and treatment of this pathology, and also describes a clinical case in which multiple PAVMs caused repeated ischemic strokes.

Exploring post acute rehabilitation service use and outcomes for working age stroke survivors (≤65 years) in Australia, UK and South East Asia: data from the international AVERT trial

OBJECTIVES

Information about younger people of working age (≤65 years), their post stroke outcomes and rehabilitation pathways can highlight areas for further research and service change. This paper describes: (1) baseline demographics; (2) post acute rehabilitation pathways; and (3) 12-month outcomes; disability, mobility, depression, quality of life, informal care and return to work of working age people across three geographic regions (Australasia (AUS), South East (SE) Asia and UK).

DESIGN

This post hoc descriptive exploration of data from the large international very early rehabilitation trial (A Very Early Rehabilitation Trial (AVERT)) examined the four common post acute rehabilitation pathways (inpatient rehabilitation, home with community rehabilitation, inpatient rehabilitation then community rehabilitation and home with no rehabilitation) experienced by participants in the 3 months post stroke and describes their 12-month outcomes.

SETTING

Hospital stroke units in AUS, UK and SE Asia.

PARTICIPANTS

Patients who had an acute stroke recruited within 24 hours who were ≤65 years.

RESULTS

668 participants were ≤65 years; 99% lived independently, and 88% no disability (modified Rankin Score (mRS)=0) prior to stroke. We had complete data for 12-month outcomes for n=631 (94%). The proportion receiving inpatient rehabilitation was higher in AUS than other regions (AUS 52%; UK 25%; SE Asia 23%), whereas the UK had higher community rehabilitation (UK 65%; AUS 61%; SE Asia 39%). At 12 months, 70% had no or little disability (mRS 0-2), 44% were depressed, 28% rated quality of life as poor or worse than death. For those working prior to stroke (n=228), only 57% had returned to work. A noteworthy number of working age survivors received no rehabilitation services within 3 months post stroke.

CONCLUSIONS

There was considerable variation in rehabilitation pathways and post acute service use across the three regions. At 12 months, there were high rates of depression, poor quality of life and low rates of return to work.

TRIAL REGISTRATION NUMBER

Australian New Zealand Clinical Trials Registry (ACTRN12606000185561).

Mortality in young adult patients with acute ischaemic stroke

OBJECTIVES

This study aimed to determine short- and long-term mortality, clinical determinants and causes of death in young patients with ischaemic stroke.

MATERIALS AND METHODS

We performed a hospital-based study of 18- to 54-year-old consecutive patients with ischaemic stroke, who were treated in the two largest hospitals in Estonia from 2003 to 2012. All cases were reviewed by the authors. Survival data and causes of death were obtained from the Estonian Population Registry and the Causes of Death Registry, respectively. Logistic regression and Cox proportional hazard models with backwards stepwise analysis were used to identify determinants of mortality.

RESULTS

We identified 738 patients, of whom 124 died during the 5-year follow-up. Cumulative mortality rates at 30 days and 5 years were 4.5% (95% confidence interval [CI], 3.0%-6.0%) and 16.8% (95% CI, 14.1%-19.5%), respectively. The proportion of deaths due to vascular causes was 87.9% at 1 month and 54.6% at 5 years. Thirty-day mortality was independently associated with severe stroke, with a National Institutes of Health Stroke Scale (NIHSS) score >15, and post-stroke infections. The determinants of 5-year mortality were post-stroke infections, structural cardiac diseases and moderate stroke severity with NIHSS score of 7-15.

CONCLUSION

The mortality rate among young patients with ischaemic stroke in Estonia is higher than that reported in previous studies and is associated with increased stroke severity, post-stroke infections and structural cardiac diseases. These results emphasize the need for more effective preventive strategies in these patient groups.

Long-term (>10-year) clinical follow-up after young embolic stroke/TIA of undetermined source

Background

To date, the pathophysiology of first-ever and recurrent stroke/TIA still remains unclear in young patients with embolic stroke/TIA of undetermined source (ESUS). Clinical studies with long-term follow-up in young ESUS patients are necessary to investigate the underlying pathophysiology of first-ever and recurrent stroke/TIA in this patient population, in particular the role of new-onset atrial fibrillation.

Aims

Our aim was to study the long-term (>10-year) clinical outcome of young patients (<50 years) with ESUS.

Methods

This cohort study included all patients aged ≤ 50 years who underwent transoesophageal echocardiography for diagnostic work-up of ESUS during 1996–2008 from one tertiary center. All patients were contacted by telephone between September–November 2018 to update clinical information from medical records. The clinical outcomes of this study were incidence rates of all-cause and cardiovascular mortality, recurrent stroke/TIA, new-onset clinical AF, and ischemic vascular events.

Results

In total, 108 patients (57% female, mean age 40 ± 7.2 years [range 19–50 years], n = 72 stroke) were included. Across clinical follow-up (median 13[IQR 10–16] years), 24 patients died (n = 14 cardiovascular). The 15-year incidence rate of recurrent stroke/TIA was 15% (incidence rate = 1.09[95%CI 0.54–1.65]/100 patient-years) and a 5.5% incidence of new-onset clinical AF (incidence rate = 0.44[95%CI 0.09–0.79]/100 patient-years) following ESUS.

Conclusions

The incidence of recurrent stroke/TIA is relatively high during long-term clinical follow-up of young patients with ESUS. In contrast, new-onset clinical AF is relatively low and therefore may not play an important part in the pathophysiology of first-ever and recurrent stroke/TIA of these patients.

Very early cognitive screening and return to work after stroke

Background: Stroke is a common cause of long-term disability worldwide, and an increasing number of persons affected by stroke are of working age. In addition to physical impairments, a majority of patients reportedly suffer cognitive impairments after stroke. Reduced cognitive function may hinder poststroke return to work (RTW); however, most studies of this relationship have assessed cognitive function months after the stroke.Objectives: The current study aims to investigate the degree of post-stroke RTW, and whether very early cognitive function screening can predict RTW after a stroke.Methods: This study included 145 persons treated for stroke at 18-63 years of age at a large university hospital in Sweden between 2011 and 2016. Data were retrieved from the GOTVED database. Within 36-48 h after hospital admission, cognitive function was screened using the Montreal Cognitive Assessment (MoCA). Full and partial RTW were assessed based on the Swedish Social Insurance Agency's register. Logistic regression was performed to analyze the potential predictors of RTW at 6 months and 18 months.Results: Neither global cognitive function nor executive function at 36-48 h after stroke predicted any degree of RTW at 6 or 18 months. Male sex, lower stroke severity, and not being on sick leave prior to stroke were significant predictors of RTW.Conclusions: Screening for cognitive impairments at 36-48-h post stroke is apparently too early for predicting RTW, and thus cannot be the sole basis for discharge planning after stroke. Additional research is needed to further analyze cognitive function early after stroke and RTW.

Intrathecal inflammation in young stroke

OBJECTIVES

Correct identification of inflammatory etiologies of stroke is of outmost importance as they require treatment of the underlying disease. Aim of this study was to determine the prevalence of inflammatory changes in cerebrospinal fluid (CSF) observed in young cryptogenic stroke patients.

MATERIALS AND METHODS

Of 6476 records of patients diagnosed with ischemic stroke, 278 had confirmed ischemia in brain imaging and received lumbar puncture. A total of 122 were classified as young stroke (≤55 years), and 156 were classified as older stroke patients; lumbar puncture in this cohort was indicated due to atypical clinical presentation.

RESULTS

An infectious etiology was detected in 2.5% of young stroke patients (n = 3: vasculitis due to opportunistic infection, vasculitis due to neuroborreliosis, secondary vasospasm after viral meningitis) and in 1.9% (n = 3) in the older stroke cohort (vasculitis due to neurotuberculosis, septic embolic ischemia, vasculitis post-haemophilus influenza meningoencephalitis). Isolated vasculitis was evident in one patient of the older stroke cohort (0.6%). Non-specific alterations in CSF included increased cell count in 10% in young and in 9.3% in the older stroke cohort. Intrathecal Ig synthesis was present in 3.4% of the younger and in 4% of the older stroke cohort.

CONCLUSIONS

The prevalence of an infectious etiology in young stroke is modest but slightly higher in comparison with older stroke patients. As brain imaging is not always sufficient for suspecting vasculitis, we recommend implementation of lumbar puncture in young cryptogenic stroke patients. If an infectious disease is present in ischemic stroke, it is of high therapeutic relevance.

Cerebral Infarction in Young Marijuana Smokers - Case Reports

INTRODUCTION

Causality of marijuana abuse with development of ischemic stroke has been indicated by numerous case reports and epidemiological studies. As a possible pathophysiological mechanism, the most common consideration is cardiac embolization during paroxysmal atrial fibrillation, systemic hypotension or multifocal intracerebral vasoconstriction.

CASE REPORTS

We present three case reports of marijuana consumers who were admitted to our comprehensive stroke center due to ischemic stroke within 18-month period of our investigation. In one case, the cause of stroke was not related to the use of marijuana, it was a manifestation of antiphospholipid syndrome. In two cases the association with the abuse of this drug is probable but not certain. In both these cases, an isolated occlusion in vertebrobasilar arterial system was detected, without finding of a cerebral vessels stenosis. Although we did not register the atrial fibrillation, we consider cardiac embolization as probable etiological mechanism of stroke in both cases. In one case, paradoxical embolization due to the persistent foramen ovale represents another potential etiological mechanism.

CONCLUSIONS

Cannabinoid use may cause ischemic stroke, especially in the younger age category. Therefore, in these patients we recommend focusing on the history of cannabinoid abuse and carry out toxicological urine tests.

Can TG/HDL Ratio be an Accurate Predictor in the Determination of the Risk of Cerebrovascular Events in Youngsters?

Objectives:

There is good evidence that shows that modification of modifiable risk factor will reduce the risk of stroke. Hyperlipidemia is one of these risk factors. Studies have shown that nontraditional serum lipid variables may be better predictors of vascular risk rather than others.

The objective of the present study was to assess the relationships of traditional and nontraditional serum lipid measurements between young and elder patients with stroke and healthy young adults.

Methods:

One hundred twelve young patients with ischemic stroke, 113 healthy adults, and 110 patients with ischemic stroke aged >45 years were included in the study. Laboratory tests for total cholesterol (TC), its fractions, and triglycerides (TGs) were performed using standard techniques, and we computed four nontraditional lipid variables.

Statistical analyses were performed using chi-square test, Student’s t-test, and SPSS version 16.0 software. A p value of <0.05 was considered statistically significant.

Results:

The mean age of 112 young patients with stroke was 38.46±5.96 years. There were 63 male and 49 female patients. Measurements of lipid parameters were as follows: low-density lipoprotein (LDL) 121.42±36.56 mg/dl, high-density lipoprotein (HDL) 38.84±12.47 mg/dl, TG 186.10±176.14 mg/dl, TC 194.76±45.35 mg/dl, LDL/HDL 3.39±1.46, TG/HDL 5.44±6.36, and TC/HDL 5.40±6.36. All lipid measurements were significantly higher in young patients with stroke than in healthy adults.

The mean age of 110 patients with stroke aged >45 years was 69.53±12.34 years. There were 63 male and 47 female patients. Measurements of lipid parameters were as follows: LDL 125.18±35.97 mg/dl, HDL 41.47±14.16 mg/dl, TG 117.53±59.03 mg/dl, TC 190.16±42.96 mg/dl, LDL/HDL 3.32±1.55, TG/HDL 3.46±3.43, and TC/HDL 5.01±2.08. TG level and TG/HDL ratio were significantly higher in young patients with stroke than in older cases.

Conclusion:

All lipid measurements were significantly higher in young patients with ischemic stroke than in young healthy adults. TG level and TG/HDL ratio were significantly higher in male than in female patients. In addition, TG level and TG/HDL ratio were significantly higher in young patients with stroke than in older cases. As the TG/HDL ratio has proven to be a highly significant independent prognostic predictor of stroke, it should be calculated in young patients with ischemic stroke.

Utility of current thrombophilia screening in young patients with stroke and TIA

Introduction

Approximately 40% of strokes in young adults are cryptogenic. The diagnostic yield of thrombophilia screening remains controversial. We aimed to determine utility of current thrombophilia testing for young patients with stroke and transient ischaemic attack (TIA).

Methods

We present a retrospective review of all patients with stroke and TIA ≤60 years presenting to University College London Hospital stroke unit and daily TIA clinic from 1 January 2015 to 1 August 2016. Consecutive clinical records and thrombophilia tests, including factor V Leiden (FVL), prothrombin G20210A mutation (PGM), antiphospholipid antibody (APA), and protein S, C and antithrombin (AT) levels, were reviewed.

Results

The mean age of 628 patients with stroke and TIA was 49.1 years (SD 9.2). Thrombophilia testing was performed in 360 (57%) patients, including 171 with stroke and 189 with TIA. Positive tests were found in 50 (14%) patients, of whom 24 patients were <50 years. Positive results were found in 36 (10%) with acute ischaemic stroke, 4 (1%) with haemorrhagic stroke and 10 (3%) with TIA. Thirteen patients (4%) had homozygous/heterozygous FVL or PGM, and 27 (7.5%) had positive APA (anticardiolipin antibody, anti-β2 glycoprotein antibody or lupus anticoagulant). Of 27 (7.5%) patients with protein C, S or AT deficiency, 10 (2.8%) had primary deficiency, presumed hereditary with other secondary causes excluded. 9% of patients with protein C, S or AT and 27% with APA were followed by confirmatory testing.

Conclusion

Thrombophilia testing was positive in only 14% of cases overall. Thrombophilia mutations and protein C, S or AT abnormalities were found rarely and were very uncommon in patients with TIA. Follow-up of abnormal results was generally poor for all groups, which further limited the impact of the thrombophilia testing policy.

Genomic screening of Fabry disease in young stroke patients: the Taiwan experience and a review of the literature

Background and purpose

Fabry disease is an X‐linked disease, and enzyme‐based screening methods are not suitable for female patients.

Methods

In total, 1000 young stroke patients (18–55 years, 661 with ischaemic stroke and 339 with hypertensive intracerebral hemorrhage) were recruited. The Sequenom iPLEX assay was used to detect 26 Fabry related mutation genes. The frequency of Fabry disease in young stroke was reviewed and compared between Asian and non‐Asian countries.

Results

Two male patients with ischaemic stroke were found to have a genetic mutation of IVS4+919G>A. There was no α‐galactosidase A (GLA) gene mutation in female patients. The frequency in Asian stroke patients was 0.62% (male vs. female 0.63% vs. 0.58%) with 0.72% for ischaemic stroke and none for hemorrhagic stroke, compared to 0.88% (0.77% vs. 1.08%) with 0.83% for ischaemic stroke and 1.40% for hemorrhagic stroke reported in western countries.

Conclusion

IVS4+919G>A is the GLA mutation in Taiwanese young ischaemic stroke patients. Fabry disease is more frequent among non‐Asian patients compared to Asian patients.

Risk factors and mechanisms of stroke in young adults: The FUTURE study

Incidence of ischemic stroke and transient ischemic attack in young adults is rising. However, etiology remains unknown in 30-40% of these patients when current classification systems designed for the elderly are used. Our aim was to identify risk factors according to a pediatric approach, which might lead to both better identification of risk factors and provide a stepping stone for the understanding of disease mechanism, particularly in patients currently classified as "unknown etiology". Risk factors of 656 young stroke patients (aged 18-50) of the FUTURE study were categorized according to the "International Pediatric Stroke Study" (IPSS), with stratification on gender, age and stroke of "unknown etiology". Categorization of risk factors into ≥1 IPSS category was possible in 94% of young stroke patients. Chronic systemic conditions were more present in patients aged <35 compared to patients ≥35 (32.6% vs. 15.6%, p < 0.05). Among 226 patients classified as "stroke of unknown etiology" using TOAST, we found risk factors in 199 patients (88%) with the IPSS approach. We identified multiple risk factors linked to other mechanisms of stroke in the young than in the elderly . This can be a valuable starting point to develop an etiologic classification system specifically designed for young stroke patients.

[Cerebral infarction related to varicella zoster virus vasculopathy]

A 14-year-old girl developed transient disturbance of consciousness, dysarthria, and clumsiness of the right upper limb 4 months after herpes zoster ophthalmicus. Brain MRI showed acute cerebral infarction in the left middle cerebral artery (MCA) territory. CT angiography demonstrated mild stenosis in the top of the left internal carotid artery and the proximal side of the MCA. Cerebrospinal fluid (CSF) examination showed slightly mononuclear pleocytosis (6/μl). Titer of the anti-varicella zoster virus (VZV) IgG antibodies in CSF was increased, and gadolinium-enhanced brain MRI (T₁-weighted imaging) revealed enhancement of the vessel walls at the stenotic lesions. Based on the diagnosis of VZV vasculopathy, methylprednisolone and valacicrovir were administered, followed by acyclovir, in addition to antithrombotic therapy using aspirin and warfarin. After these treatment, her right upper clumsiness was resolved and gadolinium-enhancement of the vessel walls was disappeared on MRI. VZV vasculopathy may cause ischemic stroke in young patients, especially in children. A careful history-taking about herpes is necessary to detect the disease as a potential cause in young stroke patients.

Twelve-lead electrocardiogram and mortality in young adults after ischaemic stroke

Introduction

Ischaemic stroke at young age carries an increased risk for mortality in comparison to the general population, but factors associated with mortality have been poorly studied. We studied the role of electrocardiogram in mortality risk stratification in young stroke patients.

Patients and methods

The Helsinki Young Stroke Registry encompasses 1008 patients aged <50 years with ischaemic stroke. We included 690 patients for this electrocardiogram substudy. Our endpoints were all-cause and cardiovascular mortality. Cox regression models - adjusted for clinical and demographic characteristics - were used to identify the electrocardiogram parameters associated with these endpoints.

Results

At a mean follow-up of 8.8 years, cumulative all-cause and cardiovascular mortality were 16.1 and 9.1%, respectively. Factors associated with both endpoints included diabetes (type 1 for all-cause, type 2 for cardiovascular mortality), heavy drinking, malignancy, as well as stroke severity and aetiology. Of the electrocardiogram parameters, higher heart rate (hazard ratio 1.35 per 10/min, 95% confidence interval 1.21-1.49), a shorter P-wave (hazard ratio 0.78 per 10 ms decrement, 0.64-0.92) and longer QTc interval (1.09 per 10 ms, 1.03-1.16) were associated with increased all-cause mortality. Only a higher heart rate (1.42 per 10/min, 1.24-1.60) was associated with death from cardiovascular causes.

Conclusions

A higher heart rate during the subacute phase after stroke is associated with an elevated risk of all-cause and cardiovascular mortality in young adults. A longer QTc interval is associated only with higher all-cause mortality. P-wave characteristics and their possible association with mortality need further studies.

Frequency and predictors of acute ischaemic lesions on brain magnetic resonance imaging in young patients with a clinical diagnosis of transient ischaemic attack

BACKGROUND AND PURPOSE

Acute lesions in patients with transient ischaemic attack (TIA) are important as they are associated with increased risk for recurrence. Characteristics associated with acute lesions in young TIA patients were therefore investigated.

METHODS

The sifap1 study prospectively recruited a multinational European cohort (n = 5023) of patients aged 18-55 years with acute cerebrovascular event. The detection of acute ischaemic lesions was based on diffusion-weighted imaging (DWI). The frequency of DWI lesions was assessed in 829 TIA patients who met the criteria of symptom duration <24 h and their association with demographic, clinical and imaging variables was analysed.

RESULTS

The median age was 46 years (interquartile range 40-51 years); 45% of the patients were female. In 121 patients (15%) ≥1 acute DWI lesion was detected. In 92 patients, DWI lesions were found in the anterior circulation, mostly located in cortical-subcortical areas (n = 63). Factors associated with DWI lesions in multiple regression analysis were left hemispheric presenting symptoms [odds ratio (OR) 1.92, 95% confidence interval (CI) 1.27-2.91], dysarthria (OR 2.17, 95% CI 1.38-3.43) and old brain infarctions on MRI (territories of the middle and posterior cerebral artery: OR 2.43, 95% CI 1.42-4.15; OR 2.41, 95% CI 1.02-5.69, respectively).

CONCLUSIONS

In young patients with a clinical TIA 15% demonstrated acute DWI lesions on brain MRI, with an event pattern highly suggestive of an embolic origin. Except for the association with previous infarctions there was no clear clinical predictor for acute ischaemic lesions, which indicates the need to obtain MRI in young individuals with TIA.

Role of tDCS in potentiating poststroke computerized cognitive rehabilitation: Lessons learned from a case study

Cognitive impairment after stroke is quite common and can cause important disability with a relevant impact on quality of life. Cognitive rehabilitation (CR) and related assistive technology may improve functional outcomes. A 30-year-old woman came to our research institute for an intensive CR cycle following a right parieto-temporal stroke. Because the patient was in the chronic phase, we decided to use 3 different rehabilitative protocols: (a) traditional cognitive training (TCT), (b) computerized cognitive training (CCT), and (c) CCT combined with transcranial direct stimulation (CCT plus) with a 2-week interval separating each session. Cognitive and language deficits were investigated using an ad-hoc psychometric battery at baseline (T0), post-TCT (T1), post-CCT (T2), and post-CCT plus (T3). Our patient showed the best neuropsychological improvement, with regard to attention processes and language domain, after T3. Our data showed that CCT plus should be considered a promising tool in the treatment of poststroke neuropsychological deficits.

Can the cardiovascular family history reported by our patients be trusted? The Norwegian Stroke in the Young Study

Background and purpose

Family history (FH) is used as a marker for inherited risk. Using FH for this purpose requires the FH to reflect true disease in the family. The aim was to analyse the concordance between young and middle‐aged ischaemic stroke patients' reported FH of cardiovascular disease (CVD) with their parents' own reports.

Methods

Ischaemic stroke patients aged 15–60 years and their eligible parents were interviewed using a standardized questionnaire. Information of own CVD and FH of CVD was registered. Concordance between patients and parents was tested by kappa statistics, sensitivity, specificity, predictive values and likelihood ratios. Regression analyses were performed to identify patient characteristics associated with non‐concordance of replies.

Results

There was no difference in response rate between fathers and mothers (P = 0.355). Both parents responded in 57 cases. Concordance between patient and parent reports was good, with kappa values ranging from 0.57 to 0.7. The patient‐reported FH yielded positive predictive values of 75% or above and negative predictive values of 90% or higher. The positive likelihood ratios (LR+) were 10 or higher and negative likelihood ratios (LR−) were generally 0.5 or lower. Interpretation regarding peripheral arterial disease was limited due to low parental prevalence. Higher age was associated with impaired concordance between patient and parent reports (odds ratio 1.05; 95% confidence interval 1.01–1.09; P = 0.020).

Conclusions

The FH provided by young and middle‐aged stroke patients is in good concordance with parental reports. FH is an adequate proxy to assess inherited risk of CVD in young stroke patients.

Paroxysmal atrial fibrillation in young cryptogenic ischemic stroke: A 3-week ECG Holter monitoring study

BACKGROUND

Atrial fibrillation is known very frequent cause of ischemic stroke. Undetected paroxysmal atrial fibrillation (PAF) is thus often considered a possible cause of cryptogenic ischemic stroke (CIS). The aim of this prospective study was to detect PAF using ECG Holter monitoring and determinate whether prolongation of the Holter monitoring to 3 weeks would increase the detection rates of PAF in young CIS patients ≤ 50 years.

METHODS

The study set consisted of IS patients ≤ 50 years enrolled in the HISTORY (Heart and Ischemic STrOke Relationship studY) study (NCT01541163). CIS was defined according to the TOAST criteria including the absence of ultrasonographic or angiographic signs of atherosclerosis, vasculitis or dissection. Admission ECG, serum levels of high sensitive Troponin T (hs TnT) and N-terminal pro-brain natriuretic peptide (NT-proBNP), markers of thrombophilia, transoesophageal echocardiography (TEE) and 24-hour ECG-Holter monitoring were performed in all patients. In case of negative 24-h ECG Holter, an additional 3-weeks monitoring was done.

RESULTS

Of the 105 enrolled patients ≤ 50 years, 95 (90%) were identified as cryptogenic (49 males, mean age 39.1 ± 8.2 years). All CIS patients had normal admission ECG. In total, PAF was detected in 9 (9.5%, 95% CI: 3.5% - 17.8%) patients; in two during 24-h ECG Holter and in seven during 3-weeks Holter monitoring. Patients with PAF had more frequently elevated admission hs TnT and NT-proBNP levels (P - 0.0001).

CONCLUSIONS

PAF was detected in 9.5% of young CIS patients and 3-weeks ECG Holter monitoring increased the detection rate.

Pattern and risk factors of stroke in the young among stroke patients admitted in medical college hospital, Thiruvananthapuram

Background:

Stroke in the young is particularly tragic because of its potential to create a long-term burden on the victims, their families, and the community. There had been relatively few studies on young stroke in Kerala's socio-economic setup, that too encapsulating the mentioned apparently relevant dimensions of stroke in the young.

Objective:

To study the prevalence, patterns and risk factors of young stroke.

Settings and Design:

A cross-sectional study with case control comparison at Government Medical College Hospital, Thiruvananthapuram, Kerala, India.

Materials and and Methods:

Total 100 stroke patients were identified over a period of 2 months, and data were collected on the basis of questionnaire developed for the purpose.

Results:

Of 100 stroke patients, 15 had stroke in the young, among which 9 (60%) had ishaemic stroke. Hypertension was the most common risk factor. Smoking, alcohol, atrial fibrillation, and hyperlipidemia were found to be more common in cases (young stroke) when compared with controls. Alcohol use and atrial fibrillation were significantly higher among young stroke patients. Physical inactivity was significantly lesser in those with stroke in the young than elderly. Atrial fibrillation emerged as an independent risk factor of stroke in the young with adjusted odds ratio of 6.18 (1.31-29.21).

Conclusion:

In all, 15% of total stroke occurred in young adults <50 years. The proportion of hemorrhagic stroke in young adults is higher than in elderly. Atrial fibrillation is identified as an independent risk factor of stroke in the young. Compared with stroke in elderly alcohol use, smoking, hyperlipidemia, and cardiac diseases, which are known risk factors, are higher in young stroke.

Detection of early cognitive impairment using AD8 in a young patient with stroke with cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy syndrome: a case report

Cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL) syndrome is a hereditary disease resulting from NOTCH3 gene mutation. The clinical presentations include migraine, recurrent stroke, and cognitive impairment. The severity of cognitive impairment varies in different stages, and early recognition poses a challenge. A 47-year-old lady presented with chronic migraine and sudden onset of hemiparesis. Magnetic resonance imaging revealed compatible findings of CADASIL, which was confirmed by mutation analysis of NOTCH3 gene. Early cognitive impairment was detected by her score of 3 in Ascertain Dementia 8 (AD8) questionnaire and confirmed by detailed neuropsychological assessments. After 21 months of follow-up, deterioration in her cognition and ability to perform instrumental activities of daily living were significant with a follow-up AD8 score of 7. Ascertain Dementia 8 questionnaire is an easy and valid screening tool for early cognitive impairment in patients with CADASIL syndrome.

Prevalence and association of lifestyle factors with extracranial carotid atherosclerosis in non-cardioembolic anterior circulation strokes in adult males less than 50 years: One year cross-sectional study

BACKGROUND

Data is scarce on prevalence of extracranial carotid atherosclerosis (ECA) in strokes <50 years and its association with lifestyle factors.

OBJECTIVE

Study role of (a) ECA in non-cardio-embolic anterior circulation young strokes, and (b) smoking and alcohol in ECA.

MATERIALS AND METHODS

Cardiovascular risk factors and evidence of ECA on carotid doppler ultrasound (CDUS) was evaluated in an one-year preliminary cross-sectional study of consecutive strokes between 20 years and 49 years. Females were excluded.

RESULTS

There were 46 male strokes (mean age 38.26 yrs), 17.39% had hypertension, 2.23% had coronary artery disease; none was diabetic. Tobacco users and alcohol consumers were 24/46 (52.17%) cases each. ECA was found in 14/46 (30.44%) cases. Seven of these 14 (50%) i.e., 7/46 cases (15.21%) had carotid occlusion, four had <50%, three had >70% stenosis. 'Smoking and smokeless tobacco use' was found in 71.42% (10/14) symptomatic carotid lesions compared to 43.75% (14/32) strokes without carotid lesions. Prevalence odds ratio for tobacco use and ECA was 3.21 (95% CI: 0.83-12.44) while that of alcohol and ECA was 1.33 (95% CI: 0.38-4.72).

CONCLUSION

Prevalence of ECA in strokes <50 years was high due to lifestyle factors which predispose to atherosclerosis at younger age.

Protein S deficiency: Recurrent ischemic stroke in young

Stroke in young poses a major health problem. Thrombophilic factors have been implicated in 4-8% of the young strokes worldwide. Protein S deficiency is a rare cause of recurrent ischemic stroke in young population. Only a few sporadic cases have been described in the literature. We are reporting a case of protein S deficiency-related recurrent ischemic stroke in a 16-year-old girl. Early diagnosis and targeted approach can help such patients to prevent recurrent thrombotic episodes.