Download Stroke in the Young: A Four

Stroke in the Young: A Four-Year Study,
1968 to 1972
BY S. JANAKI, F.R.C.P. (U.K.)/ J. K. BARUAH, M.D., S. R. JAYARAM, M.D.,
V. K. SAXENA, M.D., 5. R. SHARMA, M.D.,* AND M. S. GULATI, M.D.
Abstract:
Stroke in
the Young:
A Four-Year
Study, 1968
to 1972
• Twenty-six patients under 20 years of age having cerebrovascular disease were studied from
1968 to 1972. Common risk factors such as hypertension, diabetes mellitus, hyperlipidemia and
heart disease were not present. Angiographical study showed a variety of abnormalities. No
consistent defect was present.
There was a high incidence of pyrexia and convulsions in the early stages of stroke and it
appears possible that some form of arteritis might have been important in the production of the
cerebral infarction.
Additional Key Words
population study
Downloaded from http://stroke.ahajournals.org/ by guest on June 16, 2017
Introduction
• Cerebrovascular disease is commonly seen in
elderly individuals, and for a long time attention has
been directed mainly to the studies in these age
groups. In the absence of hypertension, ischemic heart
disease, and diabetes mellitus in young patients, the
etiology of cerebrovascular disease is perplexing.
The purpose of this study was to find out the frequency and possible pattern of etiological factors for
cerebrovascular disease in young patients (below 20
years of age).
Methods
During the period of January 1968 to September 1972, 26 of
270 patients having cerebrovascular disease were between 1
and 20 years of age. These patients were studied in the
Neurology Department of the G. B. Pant Hospital attached
to Maulana Azad Medical College, New Delhi, India. A
detailed history and examination were performed.
Laboratory studies included: urinalysis, white blood count,
red blood count, blood hemoglobin, differential blood count,
LE cell preparation, blood cholesterol, and x-rays of the
chest and head. An ECG and EEG were done in selected instances. Pneumoencephalography was performed in all
patients up to 13 years of age. Percutaneous carotid
angiography, on the side of the cerebral lesion, was performed in each instance. When necessary, these special
studies were carried out under general anesthesia.
The following classification of the temporal profile was
followed.
(1) Transient ischemic attack (TIA), in which there was
short duration of focal impairment of neurological function,
disappearing within 24 hours.
(2) Progressing stroke (stroke-in-evolution).
(3) Completed stroke. The catastrophe had occurred
From the Department of Neurology, M. A. Medical College and
Associated Irwin and G. B. Pant Hospitals, New Delhi, India.
•Professor of Radiology.
318
TIA
incidence
risk factors
age
recently but progression had stopped and the evidence of a
focal neurological lesion had persisted for more than 24
hours.
Results
Age and sex distribution is given in table 1. The distribution of categories of temporal profile is displayed
in table 2. The various causes of pyrexia are presented
in table 3.
Focal as well as generalized seizures were present
in 14 cases, more commonly in females.
Twenty-five of the 26 patients were right-handed.
The internal carotid artery territory was the site of the
lesion in 20 of the 26 patients. Six patients had clinical
findings suggesting cortical venous sinus involvement;
these patients had puerperal pyrexia and focal convulsions before the development of weakness.
Five patients had some form of tuberculosis (one
had tubercular meningitis). Only one patient had
rheumatic heart disease.
No patient was diabetic or hypertensive and the
blood cholesterol level was within normal limits in
every patient. LE cell preparation was negative in all
instances and the cerebrospinal fluid examination was
normal except for the patient with tuberculous
meningitis.
Details concerning carotid angiography are displayed in table 4.
Pneumoencephalography, performed in all
patients up to 13 years of age, revealed ventricular
dilatation on the ipsilateral side and the quantity of
the dilatation appeared to have a direct relationship
with the duration of the cerebral infarction.
EEG was abnormal in 12 of 20 instances. The abnormalities consisted of focal slowing on the ipsilateral side (six cases), diffuse slowing (two cases),
focal slowing with asymmetry (two cases), and
Stroke, Vol. 6, May-June 1975
STROKE IN THE YOUNG
TABLE 1
this new study of 26 patients up to 20 years of age,
36.4% had antecedent febrile episodes. It appears
possible that these inflammatory illnesses had an important role in the pathogenesis of the cerebral infarction. Over half of the patients had convulsive episodes
immediately prior to the onset of the focal
neurological abnormality. Similar observations were
reported by Banker2 and Srinivas.3
Kapoor et al.4 emphasized the meager role of
hypertension and diabetes mellitus in the pathogenesis
of stroke in young individuals. In these 26 patients it is
also true that hypertension, diabetes mellitus, and
hyperlipidemia were not detected.
Lesions thought to be arteritic were detected in
the angiogram in five instances. A variety of other
angiographical abnormalities were noted, superior
sagittal sinus thrombosis probably being very important but occurring in only two instances. Carotid
artery occlusion occurred only once. Thus, it is apparent that the results of angiography did not provide
understanding of the pathogenesis in most instances.
Distribution According to Age and Sex
Sex
Male
Female
Total
1-3
1
0
1
4-6
7-9
2
0
2
Tears
14-17
10-13
2
1
3
3
1
4
1S-10
Total
4
9
13
13
13
26
1
2
3
TABLE 2
Mode of Presentation
Completed stroke
Progressing stroke
TIA
Male
Female
Total
9 (34.50)
2 ( 7.68)
2 ( 7.68)
10 (38.46)
3 (11.62)
19 (75.02)
5 (19.30)
2 ( 7.68)
Numbers in parentheses are percentages.
Downloaded from http://stroke.ahajournals.org/ by guest on June 16, 2017
asymmetry (two cases) manifested only after carotid
compression.
Acknowledgment
Discussion
Previously, we have reported the high incidence of
stroke in patients below 40 years of age.1 However, in
We wish to thank Mr. A. S. Bhatnagar, Mr. Chattar Singh and Dr.
Tanga, who were responsible for the EEG records, and Dr. S. R.
Sharma, who was responsible for the angiography.
TABLE 3
Possible Etiological Factors in the Development of Stroke
Female
Male
Pyrexia
Mastoiditis
Upper respiratory infection
Tubercular meningitis
Puerperal sepsis
Nonspecific
Convulsions
Generalized
Focal
Headache
Trauma
Sudden unconsciousness
No.
%
No.
4
13.36
3.84
3.84
—
—
7.68
19.2
7.68
11.52
7.68
3.84
3.84
6
1
1
—
—
2
5
2
3
2
1
1
Total
%
23.04
—
—
3.84
13.36
3.84
34.56
23.04
11.52
3.84
3.84
1
4
1
9
6
3
1
1
—
—
No.
%
10
1
1
1
36.4
3.84
3.84
3.84
13.36
11.52
53.76
30.72
23.04
11.52
7.68
3.84
4
3
14
8
6
3
2
1
TABLE 4
Carotid Angiography
Left
No
Normal
Kink
Loop
Internal carotid occlusion near origin
Superior sagittal sinus thrombosis
Arteritis
Total
Stroke, Vol. 6, May June 1975
4
1
3
—
1
1
10
Right
Total
%
No.
%
No.
%
15.38
3.84
11.53
—
3.84
3.84
38.46
4
3
3
15.38
11.53
11.53
3.84
3.84
15.38
61.53
8
4
30.76
15.38
23.07
3.84
7.68
19.23
100.00
1
1
4
16
6
1
2
5
26
319
JANAKI, BARUAH, JAYARAM, SAXENA, SHARMA, GULATI
Bansal BC, Prakash C, Jain AL, et al: Cerebrovascular disease
in young individuals below the age of 40 years. Neurol (India)
21:11-18, 1973
Banker BQ: Cerebral vascular disease in infancy and
childhood. I. Occlusive vascular diseases. J Neuropath Exp
Neurol 20:127-140, 1961
Srinivas K, Arjundas G, Velmurugendran CC, et al: Strokes in
children. Proceedings of the first All India workshop conference on stroke. Indian Council of Medical Research,
Technical report Series No. 23, p 52-53, 1971
4. Kapoor S, Chandra Kl, Chopra JS, et al: Biochemical,
haematological and radiological study of cerebrovascular accidents in young subjects. Proceedings of the first All India
workshop conference on stroke. Indian Council of Medical
Research Technical report Series No. 23, p 37, 1971
Downloaded from http://stroke.ahajournals.org/ by guest on June 16, 2017
320
Stroke, Vol. b. May-June 1975
Stroke in the Young: A Four-Year Study, 1968 to 1972
S. JANAKI, J. K. BARUAH, S. R. JAYARAM, V. K. SAXENA, S. R. SHARMA and M. S.
GULATI
Stroke. 1975;6:318-320
doi: 10.1161/01.STR.6.3.318
Downloaded from http://stroke.ahajournals.org/ by guest on June 16, 2017
Stroke is published by the American Heart Association, 7272 Greenville Avenue, Dallas, TX 75231
Copyright © 1975 American Heart Association, Inc. All rights reserved.
Print ISSN: 0039-2499. Online ISSN: 1524-4628
The online version of this article, along with updated information and services, is located on the
World Wide Web at:
http://stroke.ahajournals.org/content/6/3/318
Permissions: Requests for permissions to reproduce figures, tables, or portions of articles originally published in
Stroke can be obtained via RightsLink, a service of the Copyright Clearance Center, not the Editorial Office.
Once the online version of the published article for which permission is being requested is located, click Request
Permissions in the middle column of the Web page under Services. Further information about this process is
available in the Permissions and Rights Question and Answer document.
Reprints: Information about reprints can be found online at:
http://www.lww.com/reprints
Subscriptions: Information about subscribing to Stroke is online at:
http://stroke.ahajournals.org//subscriptions/