Non-atherosclerotic arteriopathy as the cause of ishemic stroke among young adults

Current therapies in ischemic stroke. Part A. Recent developments in acute stroke treatment and in stroke prevention

Stroke is the third leading cause of death with an increasing prevalence. In previous years many important achievements and new therapeutic strategies have been established. This article provides an overview on recent developments and is an update to the article of Green et al. that was published in 2004. As this article is a comprehensive review we divided it in two parts. In this Part A of our review, recent developments in acute stroke treatment and in stroke prevention are described. In Part B we will reflect on neuroprotection.

[The most frequent causes of ischemic stroke in young adults]

INTRODUCTION

Pathogenesis of ischemic stroke in young adults is heterogeneous, thus making differential diagnosis very broad.

MATERIAL AND METHODS

The study comprised 60 ischemic stroke patients of both sexes aged 15-45 years who were treated at the Department of Neurology of the Clinical Centre of Vojvodina. Information about sex and age, detailed history, risk factors for ischemic stroke were obtained for all patients who underwent neurological examination as well. Diagnostic procedures applied in all patients included brain computed tomography and/or magnetic resonance imaging, routine laboratory tests, Doppler imaging of extra and endocranial blood vessels and coagulation tests. Contrast and/ or transesophageal echocardiography, immunological blood assays, magnetic resonance angiography and/or computed tomography angiography and/or conventional angiography, immunological tests, assessment of levels of natural coagulation inhibitors, toxicological examination, etc. were performed in selected patients.

RESULTS

Causes of ischemic stroke were determined according to the Trial of ORG 10172 in Acute Stroke Treatment criteria. The most frequent were the so called other causes of ischemic stroke, which were found in 26.7% patients. The second most frequent cause was cardiac embolisation, found in 25%. The cause of ischemic stroke remained undetermined in 21.7% of all patients.

CONCLUSION

Aetiology of ischemic stroke in young adults is diverse and demands thorough diagnostic evaluation.

[Factors predisposing to cervical artery dissection]

INTRODUCTION

Cervical artery dissection is a major cause of cerebral ischemia in young adults and can lead to various clinical symptoms, some of which are benign (e.g. headache, neck pain, Horner's syndrome, and cranial nerve palsy). However, most patients have a stroke or transient ischemic attack.

EPIDEMIOLOGY

The incidence of cervical artery dissection is low and is estimated to be around 2.6 per 100,000 inhabitants. Mortality and short-term recurrence rates are low: however; they may have been underestimated.

PATHOPHYSIOLOGY

Although the pathophysiology is still unclear constitutional and partly genetic susceptibility of the arterial wall has been proposed as a causal factor; triggered by infection or minor trauma. PREDISPOSING FACTORS: In addition to the trauma to the neck, other risk fractors have been suggested, such as infection, migraine, hyperhomocisteinamia, and the 67TT genotype of the 5,10-methylene-tetrahydrofolate reductase gene although evidence is sparse.

GENETIC FACTORS

Cervical artery dissection is now considered a multifactorial disease caused by several genetic abnormalities and environmental factors acting synergistically.

CONCLUSION

Research aimed at improving our understanding of the environmental and genetic factors predisposing to cervical artery dissection and assessment of long-term outcomes of this disease is needed. Better understanding of the underlying pathophysiology and the natural history of the disease through large prospective multicentre cohorts could also be helpful to improve therapeutic and preventive strategies. Several mutlticentre efforts are already under way to meet these needs.

Vascular dementia: Clinical and neuroradiological correlation

All stroke patients admitted to Banjaluka Clinical Centre during one year were evaluated by the standard protocol during the hospitalization and three months after the stroke. It included clinical, functional and neuropsychological examination and neuroimaging. Dementia was diagnosed according to the criteria of National Institute of Neurological Disorders and Stroke-Association Internationale pour la Recherche et l?Enseignement en Neurosciences. Demographic and clinical variables were examined. After the exclusion of the patients who died (n=139) and those who refused to be interviewed during the 3-month follow up (n=52) and those with pre-stroke dementia (n=22), a total of 273 (58.8%) patients underwent neuropsychological examination 3 months after the stroke. Fortynine (19.52%) of them met the criteria for vascular dementia. The predictors of vascular dementia were age, atrial fibrillation, cognitive and functional impairment on admission and functional outcome, subcortical lacunar infarctions, leukoaraiosis, multiple and bilateral brain lesions. Dementia is frequent after stroke and it cannot be determined by a single factor. A combination of several factors increases the critical threshold for cognitive decline.