Arta Neurol. Scandinav. 5.

5, 123-130, 1977

Department of Neurology, University Hospital, I.und, Sweden.

THE PROGNOSIS OF ISCHEMIC STROKE I N YOUNG ADUL'l'S

BENGTHINDFELT
and OLLENILSON

ABSTRACT

The report provides prognostic information on 60 patients (aged 16 to

40 years) with ischemic stroke. Immediate mortality from stroke is low
and long-term mortality is due to other causes t h a n cerehrovascular
disease. The recovery from neurological deficits is good except for
patients with occlusions of t h e internal carotic artery or the proximal
p a r t of t h e middle cerebral artery. Reinfarction is rare (about 0.5 per
cent annually) and other late neurological complications do not
seriously affect long-term prognosis. 3lore t h a n 80 per cent of the
patients will he ahle to resume work on a full o r part-time basis.

Although ischemic stroke in young adults is rare (Sjiistriim 1967) it is

a n important cause of persistent medical and social disability in this
age group. I n comparison with the older patient, the young patient with
stroke may have a greater chance of overcoming residual symptoms
with time, yet the stroke will have a considerable impact on the
patient's future. Thus, it is imperative to the patient and the family to
be informed about the outlook as early as possible after the stroke in
order to plan for appropriate future arrangements. Since stroke in
young adults is infrequent most physicians do not have enough experi-
ence t o provide a n adequate prognostic statement. Detailed prognostic
information is sparse and in fact, we have not been able to find any
comprehensive report covering medical and social prognosis of stroke
in young adults. Consequently, we want to report the results of a
long-term study of a series of young patients with ischemic stroke who
have been cared for a t our clinic.

MATERIAI,

Over the period 1965 to 1975 a total of 64 patients, 41 male and 23 female, aged 16 to
20 years (mean 30.8 years), with acute ischemic stroke were admitted to the Depart-
ment of Neurology, University Hospital of Lund. Diagnosis was based on history,
clinical examination and laboratory findings. With few exceptions diagnosis was
 124
confirmed by selective angiography. A detailed survey of this series, with respect to
pathogenetic mechanisms, has been published ( H i n d f e l t & N i l s s o n , in press) and
the reader is referred to that report f o r further details. After the stroke most
patients have been followed on an out-patient basis.
The report will provide prognostic information on 60 (39 malk and 2 1 female)
of the 64 patients. F o u r patients have not been seen at the clinic since the time of
the stroke. A search for these patients failed. According to social registers all four
patients should be alive and from second hand information a t least two of them
have recovered completely. For some reason o r other they have not wished to
cooperate in a follow-up. Of the remaining patients 3 9 ( 2 4 male and 15 female) had
suffered from infarcts within the territory of the internal carotic artery (including
the anterior and middle cerebral arteries) and 1 9 had had vascular occlusions
within the vertebro-basilar system (including the posterior cerebral artery). In
two patients a topographic diagnosis could not be ascertained.
The 60 patients have been followed for a total of 3008 months (by July 1, 197(i),
with an average follow-up of 5 1 months (rt 5.0 months S.E.M.); range 0.1 ( 3 days)
to 138 months.

RESULTS

Twelve patients received some kind of treatment during the acute

stage of the stroke. Anticoagulant therapy was tried in nine, most of
whom had a progressive onset of the stroke. Four patients were treated
with steroids; in one this was combined with anticoagulant therapy.
Treatment with glycerol was given to one single patient along with
steroids. T h e rationale for therapeutical trials h a s been variable. The
number of patients is too small to allow any conclusions as to whether
or not the early instituted treatment has had any effect on the outcome.
Medical prognosis. Two of the 64 patients died from the stroke. Both
patients had infarcts within the territory of the middle cerebral artery
and exhibited typical rostral-caudal deterioration refractory to medical
treatment. T h e remaining 62 were dismissed from the hospital and
survived the first month after the stroke. Four have not been traced
(see above) and of the remaining 58 six have died from various causes.
Two died from complications due to diabetic vascular disease, two
succumbed from uremia (secondary to systemic lupus erythematosus
and Takayashus syndrome), one (suffering from diabetes mellitus)
died from a cerebral glioma and another from cardiac insufficiency due
to rheumatic endocarditis. None of these patients had any recurrent
ischemic stroke and none died from cerebrovascular disease. I n these
cases the stroke should be considered as a manifestation of their
systemic illnesses.
T h e frequency and extent of neurological residual symptoms is
shown in Table 1. T h e deficits have been separated into three cate-
gories : minor, moderate and severe. Minor deficits include slight motor
 125

or sensory defects, a visual field defect, very minor disturbances of

language, increased fatigue and unspecific complaints (some dizziness,
unsteadiness etc.) . A hemiparesis, a hemisensory defect, dysphasia,
disturbances of cognition and mentation and multiple pareses of
cranial nerves have been classified among moderate deficits while a
dense hemiplegia, a marked hemisensory defect, aphasia and prom-
inent disturbances of mentation, severe and multiple brainstem and
cerebellar symptoms are included in the last category, disabling
deficits. T h e table provides a rough estimate of recovery. At follow-up
a considerable number of patients denied any neurological symptoms
a t all and only a very small minority was severely disabled. Thus, in
general terms prognosis with respect to the neurological deficits is
good and only about ohe fourth of the patients will have persistent
symptoms of moderate or disabling severity. During the first 2 months
after the stroke recovery is rapid and long-term regress will contribute
only to a minor extent to the restitution (Table 1 ) .

Table I . The neurological deficits at the time o f the stroke, at 2 months after the
stroke and at follow-up (see t e x t ) .

2 months after
Acute stage At follow-up
the stroke

No deficits 0 11 20
Minor deficits 16 22 18
Moderate deficits 12 12 6
Severe deficits 24 7 8

Total number of patients 52 52 52

Prognosis with respect to the location of the vascular occlusion is

shown in Table 2. A s indicated by the data, a n unfavourable prognosis
accompanied occlusions of the major vessels, i.e. the internal carotic
artery and the middle cerebral artery. More distally located occlusions
carried a better prognosis (see also Discussion).
In Table 3 the patients have been separated into two groups with
respect to pathogenesis. One group lacked any known predisposition
to stroke. I n the other group a predisposing condition was found, in-
cluding cardiac disease, arterial hypertension, diabetes mellitus, ar-
teritis, a recent head trauma, migraine, pregnancy and post-partum
state, alcoholism, abnormalities of blood coagulation and viscosity (see
also Hindfelt & Nilsson, in press). Oral contraceptive medication h a s not
heen considered a probable predisposing factor--in accordance with our
 Table 2. Prognosis w i t h respect t o the site of the vascular occlusion (see t e x t ) .

Acute stage At follow-up

Deficits
None Minor Moderate Severe None Minor Moderate Severe

Internal carotic artery Dx 0 2 - - 2 - - -

Sin 0 1 1 6 1 1 1 5

Middle cerebral artery Dx 0 - - -

(proximal part) Sin 0 - - 4

Middle cerebral artery Dx 0 4 2 1 5 2 - - c

ta
~ u
a
(distallly) Sin 0 1 4 5 4 5 1

Anterior cerebral artery Dx 0 - - 1

Sin 0 - 1 -

Posterior cerebral artery Dx 0 5 2 1

Sin 0 2 2 1

Basilar artery 0 1 - 4 1 3 1 -
(including branches)

Patient with reinfarction and both posterior cerebral arteries occluded.

 127

earlier results (see also McDowell ef al. 1968). A s is evident from the
table, the initial defects were comparable between the two groups.
Long-term prognosis did not differ with the possible exception for the
last group of severely disabled patients. I n these cases the lack of a
predisposing condition seemed to be associated with a more favorable
outcome. I t should he added that the eight patients who died from the
stroke o r from some other disease during the observation time all
belonged to the group with a recognized predisposing factor. The
frequency and variety of neurological and other complications (see
below) did not differ between the two categories.

Table 3. The extent of initial and long-term neurological defects in patients w i t h

and w i t h o u t a condition predisposing to stroke (see t e x t ) .

Acute stage At follow-up

Patients w i t h
a predisposing factor
No deficits 0 10
Minor deficits 9 8
Moderate deficits 6 3
Severe deficits 14 7
28 28

Patients lacking
a predisposing factor
No deficits 0 10
Minor deficits 7 10
Moderate deficits 7 3
Severe deficits 10 1

24 24

Complications. Fourteen patients reported recurrent neurological symptoms. Five

patients, all with supratentorial infarctions, developed post-apoplectic epilepsy
with focal and grand ma1 seizures. The first seizure occurred 6 months to 11 years
after the stroke. Medical treatment was satisfactory in every case and the epilepsy
did not add significantly to the patients handicaps.
Reinfarctions occurred in four patients, two males and two females. In three of
them a predisposing factor had already been documented at the time of the first
stroke. One male suffered from polycythemia secondary to congenital heart ab-
normality (tetralogy of Fallot) and the other was a chronic alcoholic with a
significant head trauma prior to the stroke. One female suffered from arteritis
within the posterior cerebral circulation.
Three patients had experienced brief episodes of transient neurological dys-
function after the stroke. The symptoms had resolved completely within 24 hours
 128
and were diagnosed as due to transitory ischemic attacks (TIA). One of these
patients had an angiographically verified arteriosclerosis (secondary to a multiple
dyscrine disorder).
The last patient had suffered from vertigo during a two week period. No other
symptoms were noticed and the vertigo was diagnosed as being due to vestibular
neuritis.
Among possible non-neurological complications, psychiatric disorders were most
frequent and temporarily incapacitating. Five patients developed psychiatric mani-
festations of a more scrious nature, interpretated as a state of reactive depression.
In one case the symptoms were those of an overt psychosis. Since four of the
patients lacked any previous history of psychiatric illness causality seems probable.
Somatic disorders, evolving during the observation period, were few and in most
instances irrelevant with respect to the neurological disease. Thus, none of the
52 patients had had any symptoms of disseminated arterial disease. Four patients
had suffered from rccidivating deep venous thrombosis, usually in a paretic lower
limb.
Proph!lZactic treatment. All patients with a condition predisposing to stroke
received prophylactic treatment if possible. Thus, arterial hypertension, diabetes
mellitus, migraine etc. were carefully controlled and adequately treated. Long-term
anticoagulant therapy (using dicumarol APE!), Ferrosan, Sweden) was given to 10 of
the 52 patients. During a total observation time of 232 months one of the 10 patients
on continuous dicumarol treatment reported occasional TIAs. Otherwise, this
therapy was uncomplicated and none of the paticnts suffered from reinfarction.
F o u r of the patients are still on anticoagulant medication. The six patients who are
no longer on such therapy have been followed for altogether 261 months and no
recurrent neurological symptoms have been reported.
Social p r o g n os i s . Most paticnts have hcen ahle to resume work on a full o r part-
time basis. Of the 52 patients, 35 returned to their jobs after an average of 5 months
sick leave (range 1 to 18 months). Another nine have found part-time work and
five of these have been successfully reeducated to cope with their handicaps. Eight
patients have been unable to resume any kind of work, due to a disabling hemi-
paresis and/or aphasia. Seven of these have had infarctions within the territory of
the left internal carotic artery. One patient has had both the posterior cerebral
arteries occluded and is disabled by extensive visual field defects.
With the exceptions mentioned, the social prognosis has been excellent. None of
the 44 patients who has resumed work requires help from another person and the
nced for special devices to facilitate ordinary living has been very limited. Family
relations seem to have been socially uncomplicated and there is only one case of
divorce. Without any exception it has been possible to provide the patients with
adequate home care after a variable period of rehabilitating measures.

DISCIJSSION

T h e main impression from this study must be that the prognosis of

stroke in young adults is favorable. Mortality from stroke is low and
long-term mortality is due to causes other than cerebrovascular disease.
I n these respects the prognosis differs from t h a t of older patients with
ischemic stroke (Baker et al. 1968, Robinson et al. 1968). The reason
 129

for these prognostic differences is the high incidence of complicating

conditions among the elderly.
T h e outcome of a cerebral infarct depends primarily on its site and
size. While the symptoms and signs depend on the affected vascular
territory, the site of the infarction will be set by the site of the occlusion
versus possible collateral circulation. T h e more proximal occlusions
carry the graver prognosis, as shown in Table 2. T h e two patients who
died from the stroke and seven of the eight patients with persistent
and severe deficits had occlusions of the internal carotic artery o r of
proximal part of the middle cerebral artery. Exceptionally, a n occluded
carotic artery was accompanied by minor neurological deficits, indicat-
ing a largely sufficient collateral circulation via the circle of Willis.
The more favorable outlook with distal vascular occlusions (Table 2 )
reflects 1 ) the minor size of the infarcted area and 2 ) the importance
of a n intact collateral circulation. W i t h a minor infarct and with a
preserved collateral circulation the risk of developing a progressive
brain edema, initiating a vicious circle, should be minimal. Gross brain
edema, evidenced by a shift of the midline structures, does markedly
influence the prognosis of stroke (Lindgren 1958) and may induce
continuous rostral-caudal deterioration.
T h e favorable prognosis of stroke i n the young person is probably
due to the low incidence of complicating cardiac and vascular diseases.
This will affect the immediate a s well as the long-term outcome.
Normal cardiac function and a largely intact vascular bed will secure
optimal conditions for collateral circulation and minimize the risk of
recurrent strokes. T h e good prognosis of the neurological deficits and
the low rate of reinfarctions in this series of young adults support such
a statement. T h e annual rate of recurrent stroke was about 0.5 per
cent, which is quite below the corresponding incidence among older
patients (5-6 per cent, Baker ef al. 1968, Ofsson ef af. 1976).
T h e present results do not claim to represent the natural course of
ischemic stroke in young adults since various kinds of prophylactic
treatment have been used when indicated. However, it is improbable
that the therapeutic measures reported have profoundly altered the
prognosis, since only a minority of the patients was subjected to
therapeutic trials. Consequently, it seems justified to state that a n
ischemic stroke in a young person carries a low immediate mortality,
is favorable with respect to neurological recovery and rarely recurrent.

REFERENCES

Baker, R. N., S. Schwartz & J. C. Ramseyer (1968): Prognosis among survivors of

ischaemic stroke. Neurology 18, 933-941.
 130

Hindfelt, B. & 0. Nilsson ( 1 9 7 6 ) : Brain infarction in young adults, with particular

reference to pathogenesis. Acta neurol. scand. (In press).
Lindgren, S. 0. (1958) : Course and prognosis i n spontaneous occlusions of cerebral
arteries. Acta psych. & neurol. scand. 33, 343-357.
Louis, S. & F. McDowell ( 1 9 7 0 ) : Age: Its significance i n non-embolic cerebral
infarction. Stroke 1, 449-453.
McDowell, F., S. Louis, A. Heyman & M. Arons ( 1 9 6 8 ) : Nan-embolic cerebral
infarction i n young adults. Cerebral Vascular Diseases, 6th Conference, eds.
Toole, Sikert & Whisnant. Grune & Stratton, New York, pp. 23-38.
O l s o n , J. E., R. Miiller & S. Bernelli (1976) : Long-term anticoagulant therapy for
TIA:s and minor strokes with minimum residuum. Stroke ( I n press).
Robinson, R. W., M. Demirel & R. LeBeau ( 1 9 6 8 ) : Natural history of cerebral
thrombosis, nine to nineteen year follow-up. J. Chron. Dis. 21, 221-230.
Sjostrom, A. ( 1 9 6 7 ) : Hospitalized cases of stroke i n a Swedish hospital region.
Stroke, Thule International Symposia, eds. Engel & Larsson. Nordiska Bok-
handelns Forlag, Stockholm, pp. 41-56.

Received August 27, 1976 B. Hindfelt, M.D.

Department of Neurology
University Hospital
S-22185 Lund
Sweden