Stroke in Young Women

Abstract

404Compared with older adults, stroke in the young (15-45 years-of-age) is associated with an additional set of risk factors and aetiologies, some which are more prevalent in or unique to the female population. The goal of this review is to discuss common conditions that are related to stroke in young women, with an emphasis on exogenous hormone use, pregnancy, and migraine with aura.1 The secondary goal is to summarize the risk factors and differential diagnosis of other causes of ischemic stroke more commonly found in young women, and to delineate other gender differences. Potential pathophysiologic mechanisms as well as possible management considerations for common situations are also discussed.The aetiology of stroke in young women may be approached in the manner outlined in the Figure. Note that non-female predominant conventional and unconventional vascular risk factors remain important causes of stroke in young women. Stroke risks exclusive to womenStroke risks exclusive to women pertain to hormonal mechanisms (usually exogenous hormones), or pregnancy and the post-partum period. Hormonal mechanismsThe role of female sex hormones in stroke risk is welldescribed. Endogenous ovarian hormones are protective against vascular disease on account of their favourable effects on lipoprotein metabolism, fibrinolysis, vascular inflammation, vasodilation and neuroprotection 2 . Conversely, exogenous hormone use increases the risk of stroke. Exogenous hormones ABSTRACT: In women ages 15-45 years, an additional set of risk factors are important in the pathogenesis of ischemic stroke. Some of these pertain strictly to women, and relate to exogenous hormones and pregnancy. Various other conditions are more common in women, which include migraine with aura, selected vascular disorders and autoimmune conditions. These differences do have implications for management in both the primary and secondary prevention of stroke in this age group.RÉSUMÉ: L'accident vasculaire cérébral chez les jeunes femmes. Chez les femmes de 15 à 45 ans, un ensemble additionnel de facteurs de risque sont importants dans la pathogenèse de l'accident vasculaire cérébral (AVC) ischémique. Certains sont propres aux femmes et reliés à la prise d'hormones et à la grossesse. Certains autres sont plus fréquents chez les femmes, dont la migraine avec aura, certaines maladies vasculaires et maladies autoimmunes. On doit tenir compte de ces facteurs de risque particuliers pour la prévention primaire et secondaire de l'AVC dans ce groupe d'âge.

Demographic and Geographic Vascular Risk Factor Differences in European Young Adults With Ischemic Stroke

“…20 Our study was unable to depict the prevalence of such risk factors, however, and despite recent advances 21 investigating risk factors predisposing to premature stroke, particularly in women, should be among the main targets of epidemiological and genetic stroke investigation. In contrast to female preponderance at younger ages, males increasingly predominated in all age groups after age of 34 years in all the regions.…”

Etiology of first‐ever ischaemic stroke in European young adults: the 15 cities young stroke study

“…Other determined etiology was found in one-quarter of young IS patients in most registries, with two exceptions: other etiology was found in more than one-third of patients in the Iowa Young Stroke Registry and only 6% of patients in the Northern Manhattan Young Stroke Study [4,21]. Other non-dissection etiology is more frequently encountered in women, reflecting the presence of sex hormone-related risks that are exclusive to women and the higher prevalence of diseases such as systemic lupus erythematosus and migraine with aura in women [34]. The higher frequency of CAD causing IS in our male patients is in accordance with recent findings from a large international dissection database [35].…”

Neurology Concepts: Young Women and Ischemic Stroke—Evaluation and Management in the Emergency Department

“…68 These include conditions such as Takayasu’s arteritis, systemic lupus erythematosus, Churg-Strauss, antiphospholipid antibody syndrome, and more rarely Sneddon’s Syndrome (a progressive noninflammatory arteriopathy associated with skin rash and ischemic stroke risk) and Susac’s Syndrome (an autoimmune condition resulting in encephalopathy, branch retinal artery occlusion and hearing loss). 69,70 Idiopathic moyamoya disease has also been increasingly recognized as a cause of ischemic stroke in younger women more commonly than in young men. 71 Finally, clinical depression, a condition more prevalent in women, 72 has been found to be associated with increased risk of stroke morbidity and mortality.…”

“…74 Rare forms of ischemic stroke are more common in young women (e.g., up to 10% of strokes in younger patients are caused by carotid or vertebral artery dissections, a more rare cause of stroke in older populations), 69 and the breadth of stroke mimics in young women (compared to men) presenting to the ED is large and diverse. 70 (Table 2)…”

“…79 This may be due to a combination of vasospasm, endothelial dysfunction, hypercoagulability, and oxidative stress, or even due to the relatively high incidence of patent foramen ovale in migraine patients with aura compared to migraine patients without aura. 70…”