Nicolas Martinez-MajanderAuthor: Dr Nicolas Martinez-Majander

Affiliation: Clinical Neurosciences, Department of Neurology, University of Helsinki and Department of Neurology, Helsinki University Hospital, Finland

Young stroke patients have better chances of survival when compared with older stroke patients, but also several additional challenges. Firstly, they are returning to active family life and work. Secondly, they face an increased risk of recurrent strokes and other cardiovascular events for much longer time in the future. These facts may raise several questions for which we, as treating physicians, do not necessarily have definite answers.

“What is my risk of this happening again?” is one of the most frequent questions. Fortunately, the overall risk of a recurrent stroke in the young has decreased over the last decades, currently being around 3% during the first year after the event, and then decreasing to 1-2% within the following years (1). Still, up to 45% of patients can experience a new ischemic event, such as transient ischemic attack, stroke, or myocardial infarction, within the next 25 years (2). The risk is highest in patients having risk factors such as smoking, peripheral arterial disease, and cardiac disease.

“Will this kill me?” Thankfully, also long-term mortality in young stroke patients has declined substantially during the past decades, but it is still highest during the first year after the stroke. Some studies show that on average the five-year mortality is between 6-11% and 10-year mortality 12-14% (3,4).

As treating physicians we need to tailor secondary prevention to the underlying etiology and additional risk factors such as high cholesterol and smoking, but also need to stress the importance of compliance.

“Will I be independent again?” A question almost impossible to answer. Looking into the numbers, younger patients recover better both in mild and severe strokes. At least 90% of young stroke patients will live independently and recover well after the event. Only approximately 3-5% remain severely disabled, needing help on their daily routines (3).  Pain, epilepsy, and neuropsychological disorders all contribute to decreased functional outcome and lower quality of life. Up to 6% of young patients can suffer central post-stroke pain (5). Other pain forms include e.g. peripheral neuropathic pain and pain caused by spasticity. Around 12% of patients have diagnosis of symptomatic epilepsy in ten years (6). Besides, a significant proportion of young stroke patients have cognitive symptoms such as fatigue, memory impairment, depression, and sleeping disorders.

“Will I be able to go back to work?” Usually young stroke patients are anxious to get back to work as soon as possible. The proportion of patients returning to work varies notably between studies (30-80%) and is inversely associated with higher NIHSS score on admission, early cognitive deficits, and low income (7,8).

“Can I get pregnant?” Finally, there are only few studies on the effect of ischemic stroke on future pregnancies, but it seems that the overall outcome is similar to those in the general population. However, a recent case-control study showed a higher incidence for pregnancy- and delivery-related complications for mothers with a previous stroke, although larger studies are needed to verify these findings (9). In another study, a total of 34% of the young women did not get pregnant following their stroke, mainly because of concern of stroke recurrence or if medically advised against (10,11).

In conclusion, young stroke patients recover better than the elderly. However, even mild symptoms interfere with everyday life. Intensive rehabilitation should be started from early on, combined with return-to-work programs and psychological support.

Useful sites for patient education:

http://www.strokeassociation.org/STROKEORG/AboutStroke/Lets-Talk-About-Stroke-Patient-Information-Sheets_UCM_310731_Article.jsp#.WZ7RulJlKUn

http://youngstroke.org

https://www.stroke.org.uk/resources/stroke-people-working-age

References

  1. Putaala J, Haapaniemi E, Metso AJ, et al. Recurrent ischemic events in young adults after first-ever ischemic stroke. Ann Neurol 2010 Nov;68(5):661-671.
  2. Arntz RM, Alebeek ME, Synhaeve NE, et al. The very long-term risk and predictors of recurrent ischaemic events after a stroke at a young age: The FUTURE study. European Stroke Journal 2016;1(4):337-345.
  3. Leys D, Bandu L, Henon H, et al. Clinical outcome in 287 consecutive young adults (15 to 45 years) with ischemic stroke. Neurology 2002 Jul 9;59(1):26-33.
  4. Varona JF, Bermejo F, Guerra JM, Molina JA. Long-term prognosis of ischemic stroke in young adults. Study of 272 cases. J Neurol 2004 Dec;251(12):1507-1514.
  5. Harno H, Haapaniemi E, Putaala J, Haanpaa M, Makela JP, Kalso E, et al. Central poststroke pain in young ischemic stroke survivors in the Helsinki Young Stroke Registry. Neurology 2014 Sep 23;83(13):1147-1154.
  6. Arntz RM, Maaijwee NA, Rutten-Jacobs LC, et al. Epilepsy after TIA or stroke in young patients impairs long-term functional outcome: the FUTURE Study. Neurology 2013 Nov 26;81(22):1907-1913
  7. Kauranen T, Turunen K, Laari S, Mustanoja S, Baumann P, Poutiainen E. The severity of cognitive deficits predicts return to work after a first-ever ischaemic stroke. J Neurol Neurosurg Psychiatry 2013 Mar;84(3):316-321.
  8. Glader EL, Jonsson B, Norrving B, Eriksson M. Socioeconomic factors’ effect on return to work after first stroke. Acta Neurol Scand 2016 Jul 21.
  9. Aarnio K, Gissler M, Grittner U et al. 2017. Outcome of pregnancies and deliveries before and after ischaemic stroke. European Stroke Journal. 2017
  10. Lamy C, Hamon JB, Coste J, et al. Ischemic stroke in young women: risk of recurrence during subsequent pregnancies. French Study Group on Stroke in Pregnancy. Neurology 2000; 25;55(2):269-274.
  11. Cruz-Herranz A, Illan-Gala I, Martinez-Sanchez P, et al. Recurrence of stroke amongst women of reproductive age: impact of and on subsequent pregnancies. Eur J Neurol 2015;22(4):681-e42

 

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