Stroke Care in Young Patients

Hindawi Publishing Corporation Stroke Research and Treatment Volume 2013, Article ID 715380, 7 pages http://dx.doi.org/10.1155/2013/715380 Clinical Study Stroke Care in Young Patients L. Tancredi,1 F. Martinelli Boneschi,2 M. Braga,3 I. Santilli,4 C. Scaccabarozzi,5 P. Lattuada,6 M. Sessa,2 L. Fumagalli,7 S. Iurlaro,8 I. Neromante,9 M. L. De Lodovici,10 D. V. Roccatagliata,4 G. Giacalone,2 M. Arnaboldi,1 V. Crespi,3 E. Agostoni,5 G. C. Comi,2 C. Ferrarese,7 and R. Sterzi4 1 Stroke Unit, Neurology Department, Azienda Ospedaliera Sant’Anna Hospital, Via Ravona 1, 22020 San Fermo della Battaglia, Como, Italy 2 Institute of Experimental Neurology (INSPE) and Stroke Unit, San Raffaele Scientific Institute, 20132 Milano, Italy 3 Stroke Unit, Neurology Department, Azienda Ospedaliera di Desio e Vimercate, 20871 Vimercate, Italy 4 Stroke Unit, Neurology Department, Azienda Ospedaliera Niguarda Cà Granda, 20162 Milan, Italy 5 Stroke Unit, Neurology Department, Azienda Ospedaliera A. Manzoni, 23900 Lecco, Italy 6 Stroke Unit, Neurology Department, Azienda Ospedaliera Ospedale San Carlo Borromeo, 20153 Milan, Italy 7 Stroke Unit, Neurology Department, Azienda Ospedaliera San Gerardo, 20900 Monza, Italy 8 Neurology Department, Azienda Ospedaliera di Lodi, 26900 Lodi, Italy 9 Neurology Department, Azienda Ospedaliera di Busto Arsizio, 21052 Varese, Italy 10 Neurology Department, Ospedale di Circolo e Fondazione Macchi, 21100 Varese, Italy Correspondence should be addressed to L. Tancredi; Received 18 September 2012; Revised 24 December 2012; Accepted 26 December 2012 Academic Editor: Alison E. Baird Copyright © 2013 L. Tancredi et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. The aims of this study were (i) to evaluate the clinical features of a consecutive series of young patients with ischemic stroke and (ii) to assess the changes in the clinical management of these patients over the study period. All consecutive cases of young adults aged 16 to 44 years, with ischemic stroke, that were admitted between 2000 and 2005 in 10 Italian hospitals were included. We retrospectively identified 324 patients. One or more vascular risk factors were present in 71.5% of the patients. With respect to the diagnostic process, an increase in the frequency of cerebral noninvasive angiographic studies and a decrease in the use of digital subtraction angiography were observed (𝑃 < 0.001 and 𝑃 = 0.03, resp.). Undetermined causes decreased over 5-year period of study (𝑃 < 0.001). The diagnosis of cardioembolism increased. Thrombolysis was performed for 7.7% of the patients. PFO closure (8%) was the most frequently employed surgical procedure. In conclusion, the clinical care that is given to young patients with ischemic stroke changed over the study period. In particular, we detected an evolution in the diagnostic process and a reduction in the number of undetermined cases. 1. Introduction In Western countries, approximately 5.5% of all strokes occur in patients who are younger than 45 years of age [1], and the occurrence of ischemic stroke in young adults is 10.8 per 100,000 per year [2]. Despite the lower mortality rate of cerebral ischemia in the young, there is a high social impact of this disease [3, 4]. Recent years have seen remarkable progress in basic and clinical stroke research, and these advances have resulted in improved clinical care and diagnostic workups, as well as a better understanding of stroke pathogenesis [5]. The most important developments in this respect are represented by the increased attention that is placed on detecting cardiac and coagulation defects, screening for novel risk factors [6], improving advanced noninvasive brain imaging strategies, and using intravenous thrombolysis during acute ischemic stroke [5]. Although there are many published reports concerning stroke in young adults [2–4, 7], only a small number of these studies considers the evolution of the clinical management of young patients with ischemic stroke [2, 8]. 2 The present work is a multicentric retrospective study that included all consecutive patients aged 16 to 44 years with ischemic stroke who were admitted to 10 Northern Italian hospitals. The objectives of the study were (i) to analyze the clinical features of this population and (ii) to examine the changes in patient clinical care over the study period, including changes in the diagnostic process and patient treatment that occurred over the study period. 2. Patients and Methods All patients aged between 16 and 44 years with acute ischemic stroke who were admitted to 10 hospitals in the Lombardy region, the most populated of Italy, between January 2000 and December 2005 were included in this study. The clinical centers were categorized as follows: seven were equipped with a stroke unit [10], and the remaining three had a dedicated stroke team but no stroke unit. Furthermore, all of the centers were homogeneous with regard to the availability of intensive care, neurosurgery, vascular surgery, neuroradiology, cardiology, and early rehabilitation. Acute ischemic stroke was defined in accordance with the Cooperative Young Stroke Study Criteria [4]. The exclusion criteria were as follows: ischemic stroke due to complications of other intracranial diseases, such as subarachnoid hemorrhage, sinus venous thrombosis, severe head trauma, or transient ischemic attack (TIA). We constructed our patient dataset by searching each hospital’s database. The medical records of all consecutive patients aged between 16 to 44 years with ICD 9 cm codes that were between 433.00 and 434.91 were retrospectively reviewed by a team of stroke neurologists to determine if the cases met the definition of ischemic stroke. All of the clinical departments of each hospital, except pediatrics (which admit patients who are younger than 16 years of age), were involved. The data were collected according to a predefined protocol. All of the following data were registered: demographic characteristics, family history, risk factors [11], neurological examination findings, diagnostic data, and the type of treatment. The evaluated stroke risk factors and applied definitions are shown in the supplemental Appendix (see Appendix: Details of registered cerebrovascular risk factors and their definitions in Supplementary Material available online at http://dx.doi.org/10.1155/2013/715380). We retrospectively applied consistent definitions for risk factors over the study period. The stroke subtypes were classified according to the following Bamford criteria [12]: lacunar infarct (LACI), partial anterior circulation infarct (PACI), total anterior circulation infarct (TACI), and posterior circulation infarct (POCI). The stroke etiology was classified according to the following TOAST criteria [13]: large-vessel disease (LV (...truncated)