Stroke in Young Adults

Stroke in young adults is surprisingly common. The differential diagnosis for potential etiologies is broader than that for older adults. Elements of the initial workup, including neuroimaging, bloodwork, and other ancillary studies, are reviewed. Emphasis is placed on areas in which the diagnostic approach to stroke in young adults differs from that for older patients. Clinical manifestations and management are usually similar to, but prognosis is often better than, those in an older population.

Introduction. This article will emphasize aspects of a diagnostic approach to young adults (up to 45 years of age) with stroke as it differs from a standard approach for older adults, with emphasis on initial work-up.

Stroke in young adults is surprisingly common. The annual stroke incidence was estimated at 34/100000 in Swedish adults under 55 years of age, and 10/100000 in a Mayo Clinic study of women ages 15 to 29. Ischemic stroke is much more common than hemorrhagic, the latter comprising 12% of strokes in the Lausanne registry for patients 30 to 45 years old.1 The ubiquity of stroke in young adults and its potential for devastating consequences mean that healthcare providers must have a high index of suspicion for stroke. This is especially true when a patient’s clinical picture is not easily explained otherwise.

Etiologies. The range of potential etiologies for stroke in young adults is broader than that for older adults. (Table) Like in older adults, stroke in younger adults is typically categorized as primarily ischemic or hemorrhagic. Ischemic etiologies include cardioembolic, atherosclerotic disease, and nonatherosclerotic cerebral vasculopathies. Hemorrhagic strokes include subarachnoid and intraparenchymal types. Of particular note in young adults are stroke causes such as hematologic disorders, substance abuse, trauma, dissections, oral contraceptive use, pregnancy and postpartum states, and migraine.

Table . Differential diagnosis of stroke in young adults (adapted from references 1, 2) ISCHEMIC Cardiac disease (including congenital, rheumatic valve disease, mitral valve prolapse, patent foramen ovale, endocarditis, atrial myxoma, arrhythmias, cardiac surgery) Large vessel disease Premature atherosclerosis Dissection (spontaneous or traumatic) Inherited metabolic diseases (homocystinuria, Fabry’s, pseudoxanthoma elasticum, MELAS syndrome) Fibromuscular dysplasia Infection (bacterial, fungal, tuberculosis, syphilis, Lyme) Vasculitis (collagen vascular diseases — systemic lupus erythematosus, rheumatoid arthritis, Sjögren’s syndrome, polyarteritis nodosa; Takayasu’s disease, Wegener’s syndrome, cryoglobulinemia, sarcoidosis, inflammatory bowel disease, isolated central nervous system angiitis) Moyamoya disease Radiation Toxic (illicit drugs — cocaine, heroin, phencyclidine; therapeutic drugs — L-asparaginase, cytosine arabinoside) Small vessel disease Vasculopathy (infectious, noninfectious, microangiopathy) Hematologic disease Sickle-cell disease Leukemia Hypercoagulable states (antiphospholipid antibody syndromes, deficiency of antithrombin III or protein S or C, resistance to activated protein C, increased factor VIII) Disseminated intravascular coagulation Thrombocytosis Polycythemia vera Thrombotic thrombocytopenic purpura Venous occlusion (dehydration, parameningeal infection, meningitis, neoplasm, polycythemia, leukemia, inflammatory bowel disease) Migraine HEMORRHAGIC Subarachnoid hemorrhage (cerebral aneurysm) Intraparenchymal hemorrhage Arteriovenous malformation Neoplasm (primary central nervous system, metastatic, leukemia) Hematologic (sickle-cell disease, neoplasm, thrombocytopenia) Moyamoya disease Drug use (warfarin, amphetamines, cocaine, phenypropanolamine) Iatrogenic (peri-procedural)

Clinical Manifestations. The clinical presentations for stroke in young adults are not unique to this age group. Sudden or subacute onset of neurologic symptoms referable to the brain should suggest stroke as a potential explanation. The presence of a given stroke risk factor does not assure that it is causative. Many young patients have multiple risk factors. Detailed history and examination, oriented toward common and uncommon etiologies, are especially important. Stroke mimics in the young adult population include multiple sclerosis and malignancy.

The physical exam should include neurologic, cardiovascular, ophthalmologic and dermatologic assessments. Relevant ocular findings include corneal arcus (hypercholesterolemia) or corneal opacity (Fabry’s disease); Lisch nodules, optic atrophy (neurofibromatosis); lens subluxation (Marfan’s syndrome, homocystinuria); and retinal perivasculitis (sickle-cell disease, syphilis, connective tissue diseases, inflammatory bowel disease), occlusions (emboli), angioma (cavernous malformation), or hamartoma (tuberous sclerosis). Among dermatologic associations are splinter hemorrhages or needle tracks (endocarditis); xanthoma (hyperlipidemia); café-au-lait spots, neurofibromas (neurofibromatosis); purpura (coagulopathy); and capillary angiomata (cavernous malformation).3

One-fifth to one-third of strokes in the young may be caused by cardioembolic phenomena. Transesophageal echocardiography (TEE) is usually indicated. Causes include congenital heart disease, valvular disease (including endocarditis) and arrhythmias. Mitral valve prolapse and patent foramen ovale are common but are typically not causes of stroke when present. An atrial septal aneurysm is less likely to be associated with stroke when found in isolation than when it occurs with other cardiac abnormalities.

Premature atherosclerotic cerebrovascular disease can be symptomatic in young adults, just as atherosclerosis can begin in childhood. The symptoms and signs are similar to those for older adults.

Cervicocephalic arterial dissections can involve the extracranial internal carotid, the vertebrobasilar system, or, less commonly, the intracranial carotid system. They are associated with major or minimal trauma, chiropractic manipulation, or can occur spontaneously. Other associations include fibromuscular dysplasia, Marfan syndrome, Ehlers-Danlos syndrome type IV, moyamoya and sympathomimetic drug abuse. Symptoms and signs may include neck pain, transient or lasting ischemia of retina, cerebral hemispheres, or posterior fossa, Horner’s syndrome, hemicranial pain, or subarachnoid hemorrhage. Extracranial ultrasound or magnetic resonance angiography (MRA) may confirm the clinical impression. Often catheter angiography is required for diagnosis.

Cerebral vasculitis should be considered for cases of ischemic or hemorrhagic stroke, recurrent strokes, stroke with encephalopathy, and stroke with fever, multifocal symptoms, skin abnormalities, or abnormal renal function or sedimentation rate. Infectious vasculitis (eg, with syphilis, tuberculosis, purulent meningitis), necrotizing vasculitis (eg, polyarteritis nodosa), vasculitis with collagen vascular disease (eg, lupus, rheumatoid arthritis), giant cell arteritis, and hypersensitivity vasculitis (eg, drug-induced) are seen much more often than primary central nervous system vasculitis.

Moyamoya is a noninflammatory vasculopathy associated with extensive collateral vasculature. It can present with transient ischemic attacks, headaches, hemiparesis, seizures, cerebral infarction, or hemorrhage. MRA screening is useful. Angiographic findings are distinctive and resemble in part a “puff of smoke”.4

Hypercoagulable states may be responsible for 2% to 7% of cases in young adults.4 Inherited (primary) thrombophilic disorders include entities that are recently described (hyperhomocysteinemia, factor V Leiden, prothrombin G20210A), well- established (deficiencies of antithrombin, protein S or protein C), and extremely rare (dysfibrinogenemia, thrombomodulin deficiency, heparin cofactor II deficiency).5 Acquired (secondary) causes include malignancy, pregnancy/postpartum states, oral contraceptive use and sickle-cell disease. Prior thromboembolic disease in a young patient or in family members should raise suspicion.4 Please refer to Dr. Trevarthen’s accompanying article for further information on this topic.

Cerebral venous thrombosis can cause ischemic or hemorrhagic strokes. Septic thrombosis usually occurs at the cavernous sinus as a complication of facial infection. Signs include proptosis, chemosis, and gaze palsies. Aseptic thromboses are seen disproportionately in women during pregnancy or postpartum periods, or while taking oral contraceptives. Presenting symptoms include headache, emesis, lethargy, and seizures. Papilledema may accompany focal signs.4, 6

Strokes induced by migraines are rare, considering that perhaps 20% of US adults may suffer migraines. Symptoms include persistent visual, motor, sensory or aphasic deficits, which began in the course of a typical migraine attack, where other causes are excluded. Mitochondrial encephalomyopathy with lactic acidosis and stroke-like episodes (MELAS) syndrome and cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL) are inherited causes of stroke which can include migraine as part of the clinical presentation.1, 4

Up to 45% of strokes in young adults are due to spontaneous intracerebral hemorrhage.4 Approximately half are lobar; one-quarter are in basal ganglia or internal capsule.7 Vascular malformations, aneurysms, hypertension, and illicit drug use are the main causes.4, 7

Investigations. The initial work-up should be as expeditious as possible to allow consideration of acute therapies, such as tissue plasminogen activator (t-PA).8 Brain computed tomography (CT) is usually the initial imaging study of choice as it is readily available and is highly sensitive for acute hemorrhage. Blood work should include a complete blood count with differential and platelet count, prothrombin time (international normalized ratio), activated partial thromboplastin time, glucose, chemistries, electrolytes, serology for syphilis, and an erythrocyte sedimentation rate.

A more detailed coagulation profile (anticardiolipin antibodies, lupus anticoagulants, protein S, protein C, activated protein C resistance, antithrombin III) is requested in patients without a firmly identified cause of stroke or if the patient or family members have a history of thromboses. It is advantageous to send such a profile prior to initiating anticoagulation, as heparin can alter interpretation of some of those assays. Therefore, consider ordering these assays at the beginning of the work-up.

Most patients should have high-quality brain magnetic resonance imaging (MRI) and often MRA.4, 9 Where available, MRI with diffusion-weighted imaging (DWI) and perfusion imaging (PI) is becoming standard. DWI-PI has the potential to distinguish irreversibly injured tissue from that which may be salvageable.10

Additional studies in initial screening include pregnancy testing, a chest roentgenogram, and an electrocardiogram. An echocardiogram (consider transesophageal), and extracranial (carotid-vertebral) Doppler ultrasound are routinely obtained, although often after initial antiplatelet or anticoagulation therapy is started.

Keep in mind the limitations of studies performed. CT will miss a minority of acute bleeds. MRI with DWI, quite sensitive for acute stroke, has an occasional false negative result (17 out of 782 patients in a recent study).11 Also, MRA’s resolution is not yet on par with conventional angiography.

Consider conventional angiography of cerebral and neck vessels for patients in whom dissection is suspected or in whom no other cause is found. Transcranial Doppler ultrasound can be helpful. Please see Dr. Ricci’s article in this issue for more information on neuroimaging.

Toxicologic studies are often productive, even when drug use is not acknowledged.

Other blood tests may include homocysteine, fibrinogen, antinuclear antibody, lipid panel, lipoprotein (a), serum protein electrophoresis, hemoglobin electrophoresis, and sickle-cell assay. Cerebrospinal fluid analysis is indicated for cases suspicious for infectious, vasculitic, or occult hemorrhage origins. Telemetry monitoring for arrhythmias is occasionally revealing.4

Prothrombin mutation G20210A testing is of uncertain utility in cerebrovascular disease, but may be appropriate for patients with a personal history of thromboembolic disease or family history of thrombophilia.5

A patient with one or more risk factors, such as migraine or diabetes, should be thoroughly investigated for other possibilities. The cause of stroke in young patients may remain undetermined in 20% to 30% of cases, even after a detailed work-up.4

Management. General management of ischemic8, 12, 13 and hemorrhagic14 strokes is similar to that for older adults and is beyond the scope of this article. Additional specific measures are oriented toward any underlying etiology found.4, 15 Primary16 and secondary17 preventive measures have recently been reviewed.

Prognosis. The outcome of stroke in young adults is better than that for older adults. In a recent study of 330 patients with first stroke or transient ischemic attack, followed for an average of 96 months, 8% died, 3% had another stroke, and 3% had a myocardial infarction. Approximately 16% were dependent, but 56% had returned to work. Unfortunately, only a minority of those who smoked at the time of their stroke subsequently stopped using tobacco.18 The overall annual recurrence rate is less than 1%.1 Prognosis is often closely associated with the underlying cause. A relatively good outcome may be found after many cases of arterial dissection. Risk of stroke recurrence is low (2% over 5 years) in women whose first stroke occurred in pregnancy.19

Conclusion. Strokes in young adults make up a significant proportion of strokes in general. A thorough investigation is recommended, looking into a broad array of potential etiologies, common and uncommon. Management is similar overall to that for older adults, with some aspects of treatment dictated by specific causes found. Health care providers must stress prevention with all of their young adult patients, especially those with identifiable risk factors. The potential for devastation is great in any case of stroke but prognosis in this population is better than that for older adults.

Source : http://www.thecni.org/reviews/11-2-p03-marcoux.htm
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Health Risk From Abortion

Abortion and Breast Cancer

The vast majority of scientific studies have shown that abortion causes an increase in breast cancer, including 16 out of 17 statistically significant studies.^[5] Studies showing that abortion increases breast cancer predate the political controversy.^[6] It is undisputed that having a baby protects against breast cancer, and thus early termination of pregnancy must increase the risk of cancer for the mother compared to carrying that same pregnancy to birth. Yet the abortion industry conceals this increased risk, just as the tobacco industry concealed its cancer risk for decades.

Dr. Janet Daling, who considers herself supportive of a right to perform abortions, brought the abortion-breast cancer link into the mainstream with her federally funded research on the topic. Her report, released in 1994, found a 50% increase in breast cancer risk due to induced abortion.^[7][8] She said, "I have three sisters with breast cancer and I resent people messing with the scientific data to further their own agenda, be they pro-choice or pro-life. I would have loved to have found no association between breast cancer and abortion, but our research is rock solid and our data is accurate."^[9] Similarly, an early study published in Japan in 1957 showed that women who have abortions have a much higher risk of breast cancer than those who decide to keep their baby.^[10]

In a peer-reviewed medical journal, Karen Malec observed that:^[11]

Thirty-eight epidemiological studies exploring an independent link [between abortion and] breast cancer have been published. Twenty-nine report risk elevations. Thirteen out of 15 American studies found risk elevations. Seventeen studies are statistically significant, 16 of which report increased risk.

Dr. Angela Lanfranchi, M.D., F.A.C.S., a specialist in breast cancer, has explained the physiology and epidemiology of the abortion-breast cancer link. She made the following observation:^[12]

This past August in Minneapolis, Patrick Carroll, director of the Pension and Population Research Institute of London, presented a paper to the largest gathering of statisticians in North America. He showed that abortion was the best predictor of breast cancer in Britain. Breast cancer is the only cancer in Britain which has its highest incidence and mortality rate among the upper rather than lower social classes. Abortion before a full term pregnancy and late pregnancy were the best explanations for this incidence. He also found that there had been a 70% increase risk of breast cancer between 1971 and 2002 and that for women between 50 and 54 years of age incidence was highly correlated with abortion.

Demographic evidence of abortion causing breast cancer includes the following. Breast cancer rates are far lower in Western countries that prohibited abortion than in those that promoted it. Ireland, which virtually bans abortion, reportedly has a lifetime rate of breast cancer of only 1 in 13, nearly half the rate of 1 in 7.5 in the United States.^[13] The rate of breast cancer increases steadily as one travels from Ireland, where abortion is illegal, to Northern Ireland, where abortion is legal but rare, to England, where abortion is common. ^[14]

In Romania, abortion was illegal under two decades of rule by the dictator Nicolae Ceausescu, and the country enjoyed one of the lowest breast cancer rates in the entire world during that time, far lower than comparable Western countries. Romania's breast cancer rate was an astounding one-sixth the rate of the United States.^[15] But after the execution of Ceausescu on Christmas Day, 1989, Romania has taken the opposite approach, embracing abortion to the point that Romania now has one of the highest abortion rates in the world.^[16] One Romanian observer decried, "The liberalization of abortions in Romania in 1990, the significant increase of the number of abortions at relatively short intervals, determined a rise in the incidence of breast and uterine cervix cancer in my country."^[17]

Studies on rats, which is accepted method for identifying what causes cancer in humans, confirm that abortion does indeed cause cancer. As Dr. Joel Brind observed, "Researchers also widely admit to the biological plausibility of abortion as an independent cause of breast cancer, through the estrogen-mediated stimulation of breast growth in the absence of differentiation. This was demonstrated experimentally in rats in the landmark experiments of Russo and Russo."^[18] Additional scientific information on the abortion-breast cancer link is available here.

An expert (Dr. Lynn Rosenberg) hired to defend abortion felt compelled to admit, under cross-examination, that a woman who increases her risk for breast cancer by having an abortion compared to carrying her pregnancy to childbirth:^[19]

Question by the attorney 'So in other words, a woman who finds herself pregnant at age 15 will have a higher breast cancer risk if she chooses to abort that pregnancy, than if she carries the pregnancy to term, (is that) correct?'

Dr. Lynn Rosenberg, 'Probably, yes.'

Question: 'Looking at that another way, let's compare two women. Let's say both got pregnant at age 15--one terminates the pregnancy, but the other carries the pregnancy to term. And both women go on to get married and have two kids, say, at age 30 and age 35. Is the risk of breast cancer higher for the woman who had an abortion at age 15 or the woman who had a baby at age 15, all other things being equal?'

Dr. Lynn Rosenberg: 'It's probably higher for the one who had an abortion at age 15.'

For information disputing the National Cancer Institute's position on the abortion and breast cancer issue see: National Cancer Institute on Abortion

Premature Birth and Abortion

"At least 49 studies have demonstrated a statistically significant increase in premature births (PB) or low birth weight (LBW) risk in women with prior induced abortions (IAs)."^[20] Premature birth tragically causes brain damage, and an array of other severe, lifelong injuries ranging from Cerebral Palsy to blindness, and few mothers would knowingly increase the risk of that happening. "There are at least seventeen (17) studies that have found that previous induced abortions increase preterm birth risk” and thereby increase debilitating Cerebral Palsy in children."^[21]

Researchers Rooney and Calhoun observed:^[22]

Large studies have reported a doubling of [early premature birth] EPB risk from two prior IAs. Women who had four or more IAs experienced, on average, nine times the risk of [extremely early premature births] XPB, an increase of 800 percent. These results suggest that women contemplating IA should be informed of this potential risk to subsequent pregnancies, and that physicians should be aware of the potential liability and possible need for intensified prenatal care.

Demographic evidence of how abortion increases premature birth includes the following:

The Centers for Disease Control and Prevention (CDC): "[T]he abortion rate for black women has been approximately three times as high as that for white women (range: 2.6--3.1) since 1991"^[23]

Science Daily's report on a study by the Washington University School of Medicine: "African-American women are three times more likely to deliver babies three to 17 weeks prematurely than Caucasian women"^[24]

The rate of premature birth is elevated by the same amount as the abortion rate, as expected if abortion increases the risk of premature birth.

Other Health Risks from Abortion

A study published in the Southern Medical Journal observed that there are higher death rates association with women who have abortion, and that these higher death rates persist over time and across socioeconomic boundaries.^[25]

A study New Zealand study found that abortion in young women may be associated with increased risks of mental health problems.^[26] The researcher in this study, who was not pro-life, was shaken by the study and had to go to four journals before he could find one who would publish it. ^[27]

The study concludes with the following statement:

These findings are inconsistent with the current consensus on the psychological effects of abortion. In particular, in its 2005 statement on abortion, the American Psychological Association concluded that “well-designed studies of psychological responses following abortion have consistently shown that risk of psychological harm is low...the percentage of women who experience clinically relevant distress is small and appears to be no greater than in general samples of women of reproductive age” (American Psychological Association, 2005). This relatively strong conclusion about the absence of harm from abortion was based on a relatively small number of studies which had one or more of the following limitations: a) absence of comprehensive assessment of mental disorders; b) lack of comparison groups; and c) limited statistical controls. Furthermore, the statement appears to disregard the findings of a number of studies that had claimed to show negative effects for abortion (Cougle et al., 2003; Gissler et al., 1996; Reardon & Cougle, 2002). ^[28]

Professor David Fergusson, lead author of the New Zealand study stated:

It borders on scandalous that one of the most common surgical procedures performed on young women is so poorly researched and evaluated. If this were Prozac or Vioxx, reports of associated harm would be taken much more seriously with more careful research and monitoring procedures." ^[29]

Another study published in the OB/GYN Survey detailed long-term physical and psychological health consequences of induced abortions.^[30]

Suicide rates among women who had abortions are six times higher than women who gave birth in the prior year.^[31] Overall, deaths from suicide, homicide and accidents were 248% higher after an abortion, as found by a 13-year study in Finland of its entire population.^[32]

In the United States, only one state (Missouri) requires that the abortionist have admitting privileges at a hospital within 30 miles of the abortion.^[33] In the other 49 states, an abortion patient can and often is left without prompt medical care by the treating physician.

One of the largest abortion providers in the United States, the Metropolitan Medical Associates of New Jersey, was shut down in 2007 by state health officials after one of its botched abortions left a 20-year-old woman in a coma for more than four weeks. She "became severely ill following the abortion and was transferred to Newark Beth Israel Medical Center where she needed blood transfusions and had her uterus removed. She also suffered a stroke due to the serious blood loss and had one of her lungs collapse."^[34] The State of New Jersey had shut down the same facility in 1993 also.^[35]

Abortion Alternatives

Optionline provides consultants that connects individuals to nearby pregnancy centers that offer the following services: free pregnancy tests and pregnancy information; abortion and morning after pill information, including procedures and risks; medical services, including STD tests; early ultrasounds and pregnancy confirmation; and confidential pregnancy options. ^[36] In addition, some of these centers provide information regarding free housing to women who are facing housing concerns.^[37]

The Liberty Godparent Foundation is a Christian organization focused on improving the lives of unwed pregnant teens, babies and adoptive families by providing two alternatives, The Liberty Godparent Maternity Home and Family Life Services Adoption Agency.^[38]

Political Action Committees

The most powerful political action committee (PAC) is EMILY’s List.^[39]. EMILY's List contributes money to Democratic candidates who support abortion-on-demand, including forced taxpayer funding of abortion. EMILY's List candidates also oppose regulations such as:

providing health information to abortion patients;

requiring that the abortionist have admitting privileges at a nearby hospital in case there is a complication; and

providing parental notification if the patient is a teenager.

Due to the influence of the abortion industry and EMILY's List, nearly every Democratic presidential candidate and senatorial candidate supports abortion-on-demand. "EMILY's List, the nation's largest political action committee, continues to be the dominant financial resource for Democratic candidates," its above-referenced website declares.

There is no comparably funded organization opposing abortion, because there are no monetary rewards to defending human life. Instead, candidates and supporters who oppose abortion are motivated by religious and ethical principles.

Legal History of Abortion in the United States

Prior to 1973 abortion was illegal in most of the United States, though a few states (such as Hawaii and New York) allowed it with restrictions.^[40] The U.S. Supreme Court's 1973 Roe v. Wade^[41] decision ruled that abortions are lawful under the U.S. Constitution up to the point at which the fetus becomes able to survive outside the womb, and an accompanying decision issued the same day captioned Doe v. Bolton essentially legalized abortion in the unlimited discretion of the abortionist at any time during pregnancy, up to and including birth. Conservatives immediately criticized these decisions as examples of Judicial Activism.

Abortion Industry and Charges of Targeting Minority Communities

According to writer George Grant, the author of Killing Angel:

"During the 1980s when Planned Parenthood shifted its focus from community-based clinics to school-based clinics, it again targeted inner-city minority neighborhoods...Of the more than 100 school-based clinics that have opened nationwide in the last decade [1980s], none has been at substantially all-white schools....None has been at suburban middle-class schools. All have been at black, minority or ethnic schools.” ^[42]

Planned Parenthood itself reported that its abortions on minorities in 1991 was 42.7% of its total abortions. ^[43]. However, during that time period, minorities comprised only 19.7% of the U.S. population.^[44]

According to Cybercast News Service: "An analysis by the Cybercast News Service compared the location of Planned Parenthood abortion clinics with population data from the U.S. Census in 2000. The results appear to bolster the charge that the organization targets black communities."^[45]

Source : http://www.conservapedia.com/Abortion
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Indomedia Groups

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