青年缺血性卒中.ppt

IschemicStrokeinYoungAdult2001/08/131.IschemicStrokeinYoungadultwDefinition：16-45y/owDistribution：3-4%ofallstrokewEtiology,clinicalmanifestation,andprognosisaredifferentfromelderlywItisimportanttofindtheetiologicfactorandtreatthemadequatelyforpreventingtherecurrenceOrvHetil2001Mar25;142(12):607-102.EpidermiologywNorthernSwedenMonica,13thirdlevelandlocalhospital,age18-44y/o,fromJan.1991-May1996,totally88caseswAnnualincidence：11.3/10000013.6mvs8.9wwCasefatalityrate：5.7%(within28days)4.8inNeuroNeurochirpol2000Nov-Dec;wIncreasedwithage：especiallyafter35y/owDramaticincreasedafter45inotherreportKristensen:Stroke,Volume28(9).September1997.1702-17093.EpidemiologywTable 1.AverageAnnualAge-andSex-SpecificIncidenceRatesofFirstIschemicStrokeinYoungAdultsinNorthernSweden,1991to1994 From:Kristensen:Stroke,Volume28(9).September1997.1702-17094.EpidemiologywTable1.AgesofYoungMenandWomenWithIschemicStrokeArchNeurol.1995;52:491-4955.EtiologywAtherosclerosisisthemaincauseofstrokeinelderly,whileemboligenous cardiopathyistheoneofthemaincauseofyoung adultAnnaliItalianidiMedicinaInterna.11(1):33-8,1996Jan-MarwCardiac embolismwasthemostcommoncauseofstrokeinptyounger than 40Stroke.30(11):2320-5,1999Nov.20018350wAtherosclerosiswas38.2%andcardioembolismwas18.1%ActaNeurologicaScandinavica.101(1):19-24,Jan2000.6.EtiologywAtherosclerosis33.3%,Prothrombotic state 15.5%,Cardiogenic9.5%OrvHetil2001Mar25;142(12):607-10wAtherosclerosis29.8%,Cardioembolism19.5%,Hematologic5.8%ArchNeurol.1995;52:491-495wSo cardioembolism and atherosclerosis are tow major cause of stroke in young adultswCause are diverse7.Etiology8.Etiology9.EtiologywAtherosclerosis:a.Largearteryb.SmallarterywEmbolism:a.Cardiogenicb.Non-cardiogenicwNon-Atherosclerosis artriopathy:a.Inflammatoryb.Non-inflammatorywHemological disorder:a.Viscosityb.CoagulopathywOthers:10.EtiologywEmbolism:a.Cardiogenic:1.Valvular:RH,prosthetic,endocarditis,MVP2.Arrhythmia:Af,sicksinussyndrome3.AMI/LV aneurysm:4.LV myxoma:5.Cardiomyopathy:11.EtiologywEmbolism:b.Non-cardiogenic:1.PulmonaryAVM:Osler-Weber-Rendusyndrome2.ASD/VSDorPOFwithshunt:3.Pulmonaryembolism:12.EtiologywNon-atherosclerosisarteriopathy:a.Inflammatory:1.Takayasusdisease:=Granulomatousarteritis,mono,無脈症2.Hepersensitivearteritis:Churg-straussdisease3.Infectious:Syphiliticarteritis,TB,HIV-associated4.Drugrelated:heroin,amphetamine5.Systemicdisease:SLE,RA,polyarteritisnodosa13.EtiologywNon-atherosclerosisarteriopathy:a.Non-inflammatory:1.Moyamoyadisease:2.Arterydissection:3.Irradiationvasculopathy:4.Fibromusculardysplasia:5.Firinoidvasculopathy:14.EtiologywHematologicaldisorder:a.Viscosity:1.MDS:CML,polycythemiavera,essentialthrombocythemia2.Multiplemyeloma:3.Leukemiab.Coagulopathy:15.EtiologywHematologicaldisorder:b.Coagulopathy:1.Hemoglobindisorder2.ProteinC/Sdeficiency3.AntithrombinIIIdeficiency4.DIC5.Anti-phospholipidantibody16.EtiologywOthers:1.Migraine2.Pregnancy3.Trauma17.18.RiskFactorStroke,Volume28(9).September1997.1702-170919.RiskfactorwAgreedbymostreportersare:1.Cigarettesmoking2.Hypertension3.HyperlipidemiaOrvHetil2001Mar25;142(12):607-10Postgraduatemedicine.81(5):141-4,149-511987Apr.ActaNeurologicaScandinavica.101(1):19-24,Jan200020.ClinicalPresentationwEmbolism:1.Suddenonsetofcorticalimpairment2.Heartconditionpredisposingtoembolism3.Maybefluctuated,andmayrecoverordeteriorat21.ClinicalPresentationwLargearteryatherosclerosis:1.Cerebralcorticalimpairment:aphasia,apraxia,anopia,agnosia,restrictedmotorinvolvement2.Historyofintermittentclaudication,TIA22.ClinicalPresentationwSmallarteryocclusion(lacunae)1.Traditionalclinicallacunarsyndromea.Puremotorhemiparesisb.Puresensorystrokec.Ataxiahemiparalysisd.Dysarthria-clumsyhande.Sensorymotorstroke2.HistoryofHTNandDMsupportsDx23.PrognosiswFirst28daysmortality:4.8/5.7%wNeurologicaldeficit(Canadianneurologicalscale)andhandicapseverity(Rankinclassification,Barthelindex)areallmuchbetterthanelderly.1/3;6mowAlthoughinfarctsizeusuallybigger(3cm)wRecurrenceriskislow:1.1-1.2annuallywOverall,prognosisismuchbetter,soaggressivetreatmentinterventionisimportant.24.AdvisedClinicalStudywCT/MRI/angiographyw12leadEKGwEchocardiogram/TEEwDupplex(carotidandICdoppler)wBCS,rheumaticprofile,autoimmuneprofile,coagulationprofile25.ConclusionwIschemiastrokeinyoungadultsmustbestudiedwithadifferentprotocolfromthatusedfortheelderly,duetothedifferenceoftheetiologyandtheprognosis.AnnaliItalianidiMedicinaInterna.11(1):33-8,1996Jan-Mar26.