Current understanding of stroke and stroke mimics in adolescents and young adults: a narrative review

 You'll have to ask your competent? doctor if all the problems in diagnosing young adult strokes have been solved. 

• young adult strokes (83 posts to December 2012)

Current understanding of stroke and stroke mimics in adolescents and young adults: a narrative review

• Avinash Sookdeo,
• Yusuf M. Shaikh,
• Mridula Bhattacharjee,
• Javaria Khan,
• Waqar Ahmad Alvi,
• Muhammad Saad Arshad,
• Arafat Hassan Tariq &
• Muhammad Muzammil 

International Journal of Emergency Medicine volume 17, Article number: 180 (2024) Cite this article

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Abstract

Background

Stroke in adolescents and young adults are uncommon, and unlike in older adults, the etiology can be a challenging puzzle to solve. Patients often lack traditional risk factors such as hypertension or may be too young for suspected atherosclerotic disease. Additionally, among this group, various stroke mimics exist that can cloud physician judgment, leading to under- or overtreatment.

Aim

There is a significant gap in the current literature and clinical evidence regarding stroke in this population. This review of the literature aims to extract important information surrounding the etiology, risk factors, diagnosis, management, and complications of stroke in younger people and address stroke mimics and how they can appear similar and different from ischemic or hemorrhagic stroke. Additionally, we discuss the importance of furthering research in this specific population in all areas due to a concerning rise in stroke frequency and unique associated disabilities.

Conclusion

The acute treatment of stroke in young patients is similar to older adults. While stroke mimics may complicate suspicion and cause hesitance, delays in stroke care should be avoided. There remains a need for research in the areas of diagnosis, management, and assessment of long-term care and challenges in this population of patients.

Introduction

Stroke in adolescents and young adults (AYA) is becoming a growing public health concern. Stroke ranks second among the most common causes of mortality worldwide, and an estimated 11 million stroke cases are diagnosed annually; among them, nearly a quarter of cases are reported to occur between the ages of 18 and 50 years [1, 2]. Recent studies have suggested an increase in stroke frequency between the ages of 15 and 39 [2]. With this, the third leading cause of increased disability-adjusted life years in 2019 will increase the burden of cost, treatment and rehabilitation in AYA to almost half of all stroke-related expenses in the U.S. by 2050 [2, 3].

Contributing factors, while many, include living in developing countries and low-resource health care systems, HIV-associated complications, and genetic predispositions such as thrombophilia, sickle cell disease and connective tissue disorders [2,3,4]. Due to the stark differences in etiology from adult-onset strokes, the difficulties clinicians face when approaching stroke in this population cannot be overlooked [5]. While clinical manifestations are similar, approaching the underlying cause and management demands a long-term nuanced approach.

Stroke mimics create management barriers due to the high degree of symptom similarity. Stroke mimics are defined as any such disease process that causes a focal neurological deficit without the involvement of any vascular component [5]. Most studies demonstrate that stroke mimics account for 20–30% of suspected-stroke presentations [6,7,8]. Given that 22% of ischemic strokes are missed in the emergency department or by neurological services (and likely higher for AYA), the early and accurate recognition of stroke and identifying its etiology, particularly in AYA, is critical due to the fatal or long-term complications, such as paralysis, depression, increased risk of recurrent strokes, thromboembolisms, and seizure disorders [9].

Strokes in AYA can be debilitating as the long-term complications extend for a greater period, compared to those who present at an older age. In addition, strokes in these populations are easily missed, as they are often confused as stroke-mimics, or sometimes strictly ruled-out early due to age. Regardless of the reason, research on strokes in this population is limited. Ethical considerations limit research for treatment consensus for adolescents, their rarity in those < 50-years old present statistical and population challenges. This review aims to compile data on stroke and present it within the context of AYA and emphasizing those that particularly address this population.