Positive outcomes have been documented in adults aged 18 to 49 years suffering from large vessel occlusion acute ischemic stroke (LVO-AIS), regardless of its specific cause. However, patients with stroke attributed to large artery atherosclerosis (LAA) tend to exhibit poorer stroke recovery scores at the time of discharge.
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“To my knowledge, this is the first comprehensive study of LVO-AIS conducted at Cleveland Clinic, focusing solely on young adults,” states G. Abbas Kharal, MD, MPH, who specializes in stroke neurology and immunology at Cleveland Clinic’s Cerebrovascular Center. “These findings indicate that LVO-AIS occurrences are not as rare among young adults as previously thought. Even though most causes remain cryptogenic, prompt treatment involving thrombolysis combined with thrombectomy demonstrates promising outcomes.”
Understanding LVO-AIS in young adults
Historically, LVO-AIS was perceived to be less prevalent among adults younger than 50 compared to older demographics; however, incidents of such strokes in younger populations have risen significantly over the last twenty years as the global prevalence of stroke in this age group continues to escalate.
While it’s acknowledged that the mechanisms leading to strokes differ between younger and older adults, there is a marked scarcity of literature addressing younger patients who experience LVO-AIS. Current research indicates that potential causes like cardioembolism and arterial dissection might be more prevalent, while the underlying reasons remain unknown in nearly one-third of these cases.
Rapid and effective treatments for patients eligible for acute intervention include intravenous thrombolysis (IVT), applicable if individuals seek treatment within 4.5 hours following their last known well time (LKW). Additionally, mechanical thrombectomy (MT) may be performed if patients present within a 24-hour window.
A comprehensive meta-analysis encompassing six randomized controlled trials assessing mechanical thrombectomy outcomes revealed that younger adults (ages 18-49) did not experience the same level of benefit from MT compared to their older counterparts. “This existing gap in data focusing specifically on young adults with LVO-AIS propelled our inquiry into the reasons for its occurrence in this demographic and the impact of treatment on their clinical outcomes — a vital aspect for enhancing healthcare delivery to these patients,” Dr. Kharal explains.
Analysis of a large experience base
The research data were meticulously gathered from a sample of 1,210 patients aged 18 to 50 who were treated for acute ischemic stroke from January 2017 to December 2021 across Cleveland Clinic’s 10 primary and comprehensive stroke centers located in Ohio. Among these individuals, 220 were identified as having LVO based on computed tomographic and magnetic resonance angiography results.
The researchers categorized patients suffering from LVO-AIS into five distinct treatment groups: those who received IVT only, MT only, combined IVT and MT, no treatment, and patients who had unsuccessful MT. The demographic details, the stroke etiology classified under the TOAST (Trial of Org 10172 in Acute Stroke Treatment) criteria, along with treatment outcomes, were systematically evaluated.
The objective was to analyze how stroke etiology and treatment modalities influenced clinical outcomes among young adults diagnosed with LVO-AIS. The NIH Stroke Scale (NIHSS) scores at discharge and 90 days post-stroke, as well as treatment interactions and stroke etiology, were scrutinized using multivariable linear regression models.
Key findings
In total, eighty-four patients underwent mechanical thrombectomy, which proved successful in 75 cases and unsuccessful in 9 instances. Additionally, 26 individuals were treated with intravenous thrombolysis. Importantly, 110 patients did not receive either intervention during their treatment process.
Outcomes from thrombectomy procedures were favorable (TICI 2b/2c/3) for 87.2% of those who underwent the operation. “This outcome significantly surpasses the 64.2% favorable rate noted within the MR CLEAN registry when comparing younger patients to older populations,” Dr. Kharal highlights. “Such findings suggest that younger adults can achieve outcomes post-thrombectomy that are, if not superior, at least comparable to those observed in older individuals.”
Notably, the median lag time from the last known normal time (LKW) to patient presentation was notably longest among those who did not undergo either MT or IVT procedures. Among this cohort, 35% of patients with an initial NIHSS score of ≤ 5 and 25% with scores ≥ 6 sought treatment more than 24 hours past LKW.
Patients receiving both IVT and MT recorded an average NIHSS discharge score that was 3 points lower than those who did not receive any treatments (P = .038). This trend was consistent across all TOAST classification categories, with the sole exception of cases attributed to large artery atherosclerosis.
Prioritizing prompt presentation
“Fifty percent of the study participants suffering from LVO-AIS did not receive any acute intervention, with approximately 25% of this group arriving too late for effective treatment,” Dr. Kharal points out. “Earlier presentation could have opened the door for eligibility in both IVT and possibly mechanical thrombectomy.”
“It is essential to elevate awareness regarding stroke symptoms in young adults,” he continues. “Data indicates that those who present swiftly and receive both IVT and MT demonstrate significantly improved outcomes. Understanding and addressing the barriers that lead to delayed presentations in this demographic is crucial. Our findings emphasize the urgent need for educational initiatives directed at young adults about recognizing stroke symptoms and the imperative of seeking immediate medical attention alongside addressing pre-existing stroke risk factors.”
**Interview with Dr. G. Abbas Kharal on Recent Findings in Large Vessel Occlusion Acute Ischemic Stroke in Young Adults**
**Interviewer:** Thank you for joining us today, Dr. Kharal. Your recent study at Cleveland Clinic focusing on large vessel occlusion acute ischemic stroke in young adults sheds light on some significant findings. Could you briefly explain what large vessel occlusion acute ischemic stroke (LVO-AIS) is and why it’s a growing concern among younger populations?
**Dr. Kharal:** Absolutely, and thank you for having me. LVO-AIS occurs when there is a blockage in one of the major arteries supplying blood to the brain, leading to a stroke. Historically, this condition has been viewed as less prevalent among adults under 50. However, our study reveals that instances of LVO-AIS have actually risen significantly over the last two decades among younger adults, which is concerning given the implications for recovery and long-term health.
**Interviewer:** That is alarming. What were the primary findings of your research regarding treatment outcomes for young adults with LVO-AIS?
**Dr. Kharal:** Our study included a large cohort of 1,210 patients aged 18 to 50 treated for acute ischemic stroke. We found that while most young patients showed positive outcomes after treatment with thrombolysis and thrombectomy, those with strokes caused by large artery atherosclerosis tended to have poorer recovery scores upon discharge. It’s also notable that younger adults did not benefit from thrombectomy in the same way older adults did, highlighting a gap in treatment efficacy that needs further investigation.
**Interviewer:** Your research indicates that the underlying causes of strokes in young adults may differ from those in older populations. Can you elaborate on this?
**Dr. Kharal:** Yes, the mechanisms leading to LVO-AIS in younger adults can include cardioembolism and arterial dissection, and intriguingly, many cases still remain cryptogenic, meaning we don’t yet know the cause. This underscores the complexity of stroke in younger demographics and the need for tailored approaches in both treatment and prevention.
**Interviewer:** You mentioned the importance of prompt treatment in improving outcomes. How does timely intervention impact recovery for these patients?
**Dr. Kharal:** Timeliness is crucial. For eligible patients, interventions like intravenous thrombolysis can be administered within 4.5 hours of their last known well time, and mechanical thrombectomy can be performed up to 24 hours after onset. Our findings indicated that faster treatment correlates with better recovery. Patients who did not receive either intervention suffered poorer outcomes, emphasizing the importance of awareness and swift action in recognizing stroke symptoms.
**Interviewer:** what are the next steps you envision for research in this area, especially for younger stroke patients?
**Dr. Kharal:** We need to investigate the long-term outcomes of young adults with LVO-AIS and explore the specific causes of strokes in this demographic. Further studies should also aim at refining treatment protocols and developing targeted prevention strategies. This research is critical for improving care and outcomes for young patients facing this serious health challenge.
**Interviewer:** Thank you, Dr. Kharal, for sharing these insights. Your work is vital for enhancing understanding and treatment of stroke in young adults.
**Dr. Kharal:** Thank you for having me. It’s a pleasure to contribute to this important conversation.
W can young adults be encouraged to seek medical attention sooner when experiencing stroke symptoms?
**Dr. Kharal:** Education is key. Many young adults may not recognize the symptoms of a stroke, which can lead to delays in treatment. Our findings highlight that those who present quickly and receive treatments like intravenous thrombolysis and mechanical thrombectomy demonstrate significantly improved outcomes. We need to create awareness about the symptoms of stroke—such as sudden weakness, difficulty speaking, or changes in vision—through community outreach and educational initiatives. It’s also important to discuss the risk factors for stroke, even in younger populations, to help mitigate these risks.
**Interviewer:** What message would you like to leave with our readers regarding LVO-AIS and young adults?
**Dr. Kharal:** The emergence of LVO-AIS in younger adults is a critical issue that warrants immediate attention. Recognizing stroke symptoms early and seeking out prompt medical intervention can dramatically improve recovery outcomes. We must enhance public awareness about this condition and encourage young people to prioritize their health by understanding the risks and signs of stroke. Together, we can work towards reducing the incidence and impact of strokes in our younger population.
**Interviewer:** Thank you, Dr. Kharal, for your insightful comments and for shedding light on this important topic. We appreciate your efforts in advancing our understanding of stroke in young adults.
**Dr. Kharal:** Thank you for the opportunity to discuss this vital research. It’s crucial that we continue to share knowledge and work towards improving healthcare for young adults experiencing strokes.
