Stroke in a Young Patient

Question 1

Ddx for stroke in a young patient

Answer 1

• Significantly larger than in an old patient because the etiology is not typically atherosclerotic.
• Some considerations include:
  
  • Trauma (particularly carotid dissection)
  • Thrombophilia
  • Paradoxical embolus syndrome (with PFO)
  • Arrhythmia
  • Vasculitis
  • Endocarditis
  • HIV
  • Sickle cell disease
  • Arteriovenous malformation

Question 2

Stroke due to carotid dissection

Answer 2

Often there is a clear traumatic event to the carotid body and an ipsilateral Horner’s syndrome

Question 3

Thrombophilias that may cause stroke in a young patient

Answer 3

• Homocysteinemia
• Protein C deficiency
• Protein S deficiency
• Antiphospholipid antibody syndrome
• Factor V Leiden
• Antithrombin deficiency
• Prothrombin promoter mutation

Question 4

Methods of detecting a PFO

Answer 4

• Transcranial Doppler bubble study
• Transesophageal echocardiogram

Question 5

Horner’s syndrome

Answer 5

Ipsilateral ptosis, miosis

+/- Anhidrosis (of distribution dependent upon the location of the lesion)

Question 6

Syndromes that predispose to spontaneous craniocervical dissection due to pathology of the arterial wall

Answer 6

• Ehlers Danlos syndrome
• Marfan syndrome
• Fibromuscular dysplasia

Question 7

Vertebral artery dissection syndrome

Answer 7

• Severe occipital and cervical pain
• Posterior circulation ischemic symptoms:
  
  • Vertigo
  • Dysarthria
  • Visual field defect
  • Ataxia
  • Diplopia

Question 8

Moyamoya disease

Answer 8

• Idiopathic noninflammatory cerebral vasculopathy characterized by progressive occlusion on large arteries in the Circle of Willis
  
  • Most commonly involves the distal internal carotid artery
• Small penetrating arteries hypertrophy in response to the occlusion, creating a web of arteries with the appearance of a puff of smoke (which is moyamoya in Japanese)
• Treatment: Encephaloduroarteriosynangiosis or superficial temporal artery-middle cerebral artery bypass (STA-MCA bypass)

Question 9

Stroke in association with drugs of abuse

Answer 9

• Can be associated with cocaine and/or amphetamines, which may both cause vasospasm

Question 10

Management recommendations for antiphospholipid antibody syndrome

Answer 10

• If antiphospholipid antibody is present in the absence of antiphospholipid syndrome, there is no evidence that treatment is of benefit (including aspirin)
• If there is true antiphospholipid antibody syndrome:
  
  • Acute thromboses should be treated with heparin bridged to warfarinization
  • If arterial thrombosis is present, aspirin should be added
  • DOACs are inferior to warfarin in APLS

Question 11

Treatment of carotid and vertebral dissections

Answer 11

Many dissections will re-canalize spontaneously after a couple months.

Stenting is reserved for patients who fail to spotaneously re-canalize after 3-6 months or those who have unstable-appearing pseudoaneurysms.

Question 12

The #1 study for diagnosing PFO

Answer 12

TEE

NOT bubble study