Stack Christopher A, Cole John W
Department of Neurology, University of Maryland Medical Center, 16 South Eutaw Street Suite 300, Baltimore, MD, 21201, USA.
Department of Neurology, Baltimore VA Medical Center, University of Maryland School of Medicine, 12th Floor, Bressler Building, Room 12-006, 655 West Baltimore Street, Baltimore, MD, 21201-1559, USA.
Curr Treat Options Cardiovasc Med. 2017 Sep 25;19(11):84. doi: 10.1007/s11936-017-0587-6.
Optimal diagnosis and management of stroke in young adults benefit from a multidisciplinary team, including a vascular neurology specialist. In addition to the "standard" vascular risk factors including smoking, hypertension, diabetes, and hyperlipidemia, one needs to consider alternative etiologies including substance abuse, carotid/vertebral artery dissections, and rare genetic conditions among others. Once a young patient is determined to have had a stroke, the next question a clinician should ask is why did this patient have a stroke? A "heart to head" diagnostic approach is recommended. A thorough history is performed, including a detailed family history with specific annotations on each family member. A thorough physical examination is necessary including a careful evaluation of the patient's general appearance, noting any joint laxity, and/or abnormalities of the skin, eyes, and heart. Findings across multiple organ systems in the patient and/or their family may indicate a genetic etiology. After an initial head CT rules out hemorrhagic stroke, additional testing should include a brain MRI, neck and cerebral vascular imaging (e.g., CTA for head and neck), transthoracic echocardiogram with a bubble study, telemetry monitoring, basic risk factor blood work (e.g., lipid panel, hemoglobin A1c, TSH, ESR, CRP, RPR, HIV, and toxicology screen), and, when appropriate, sickle screen and pregnancy test. There should be a low threshold to obtain blood cultures or a lumbar puncture. The acute treatment of ischemic stroke in young adult patients does not differ from treatment of older adults, using intravenous alteplase within 4.5 h, assuming no contraindications. In suspected proximal large artery occlusive disease, interventional clot extraction procedures should be employed in patients deemed eligible. Long-term secondary prevention strategies aimed to reduce recurrent stroke risk by targeting and modifying vascular risk factors should be instituted. The mainstay of preventative therapy is aspirin for most etiologies; however, for atrial fibrillation, anticoagulation is recommended. Statin therapy is another pharmacologic intervention recommended in most stroke patients. Other measures employed are blood pressure reduction, smoking cessation, optimal glucose control in diabetic patients, the initiation of a healthy diet and regular exercise, and lastly, substance abuse counseling in appropriate patients.
年轻成人卒中的最佳诊断和管理受益于多学科团队，其中包括血管神经科专家。除了吸烟、高血压、糖尿病和高脂血症等“标准”血管危险因素外，还需要考虑其他病因，包括药物滥用、颈动脉/椎动脉夹层以及罕见的遗传疾病等。一旦确定年轻患者发生了卒中，临床医生应提出的下一个问题是该患者为何会发生卒中？建议采用“从心到脑”的诊断方法。进行全面的病史采集，包括详细的家族史，并对每个家庭成员进行具体注释。进行全面的体格检查是必要的，包括仔细评估患者的一般外观，注意任何关节松弛以及皮肤、眼睛和心脏的异常情况。患者和/或其家族多个器官系统的检查结果可能提示遗传病因。在初始头部CT排除出血性卒中后，进一步检查应包括脑部MRI、颈部和脑血管成像（如头颈部CT血管造影）、经胸超声心动图及气泡试验、遥测监测、基本危险因素血液检查（如血脂谱、糖化血红蛋白、促甲状腺激素、红细胞沉降率、C反应蛋白、快速血浆反应素试验、HIV和毒理学筛查），并在适当情况下进行镰状细胞筛查和妊娠试验。进行血培养或腰椎穿刺的阈值应较低。年轻成人缺血性卒中的急性治疗与老年患者的治疗并无不同，在无禁忌证的情况下，应在4.5小时内使用静脉注射阿替普酶。对于疑似近端大动脉闭塞性疾病，应在符合条件的患者中采用介入性血栓清除程序。应制定旨在通过针对和改变血管危险因素来降低复发性卒中风险的长期二级预防策略。对于大多数病因，预防性治疗的主要药物是阿司匹林；然而，对于心房颤动，建议进行抗凝治疗。他汀类药物治疗是大多数卒中患者推荐的另一项药物干预措施。采用的其他措施包括降低血压、戒烟、对糖尿病患者进行最佳血糖控制、开始健康饮食和定期锻炼，最后，对合适的患者进行药物滥用咨询。
