Stroke in the young.

Abstract

We applaud the efforts of Carolei et all to bring some order to the hitherto neglected subject of ischemic stroke in the young. However, we have doubts that their methodology was adequate to seriously determine pathogenesis.The study was conducted during [1984][1985][1986][1987][1988], before the widespread use of transesophageal echocardiography (TEE) showed how frequently cardioembolic stroke occurs and before present knowledge of the role of aortic disease in stroke. Preliminary results of our study in a hospitalized control group showed an odds ratio of 4.6 (confidence interval, 1.5 to 14.0) for OC use, proving the contribution of this risk factor to the etiology of cerebral ischemia in young women.The ongoing 5-year follow-up of our prospective series of 333 young adults indicated that after OC discontinuation, no recurrence of nonfatal and fatal ischemic events occurred, which casts serious doubts on the fallacious hypothesis of a suggested protective effect of OC against mortality from circulatory disease.5Our patients with normal transthoracic echocardiography did not undergo TEE, which was not available (as we specified in our paper) when the protocol was defined. TEE could have contributed to increasing the percentage of new but still "putative" cardioembolic sources, such as patent foramen ovale, atrial septal aneurysm, left atrial appendage thrombi, and aortic arch plaques, thus decreasing the percentage of undetermined or unknown etiologies in the young. However, in a more recent series,6 TEE did not prove as helpful as expected despite the invasive approach in the management of cerebral ischemia.