Introduction. Stroke in people under 45 years of age is less frequent than in older populations but has a major impact on the individual and society. In this article we provide an overview of the epidemiology and etiology of young stroke. Methods. This paper is based on a review of population-based studies on stroke incidence that have included subgroup analyses for patients under 45 years of age, as well as smaller community-based studies and case-series specifically examining the incidence of stroke in the young. Trends are discussed along with the relative frequencies of various etiologies. Discussion. Stroke in the young requires a different approach to investigation and management than stroke in the elderly given differences in the relative frequencies of possible underlying causes. It remains the case, however, that atherosclerosis contributes to a large proportion of stroke in young patients, thus, conventional risk factors must be targeted aggressively.
Abarbanel (1945) has pointed out, the process of ageing can become manifest in various organs at varying times, and just because the testis may be one of the last to succumb does not mean that it has now become the site of a pathological process while a similar state in the ovary is merely physiological.Summary It is considered that the male climacteric is a definite clinical entity, for the following reasons: (1) Similar symptoms occasionally occur in post-pubertal castrates and eunuchoids and are improved by androgen therapy.(2) The 17-ketosteroid secretion, while by no means diagnostic of testicular insufficiency, tends to be low. (3) Some of the symptoms can be explained by lack of the anabolic action of testosterone. (4) The urinary excretion of gonadotrophin is raised-indicative of testicular, but not necessarily of androgen, insufficiency. (5) The testicular histology may show structural changes. (6) The symptoms are improved with androgen therapy, but relapse when an inert substance is substituted. (7) Arguments similar to those advanced against the concept of a male climacteric could be raised against the existence of a female climacteric, which, however, has never been questioned.
Background Autoimmune encephalitis is an increasingly recognised disease that presents with seizures, neuropsychiatric symptoms, dystonic movements, and autonomic dysfunction 1 . As the mainstay of treatment immunosuppressive therapies are most effective when subject to early initiation and timely escalation, both of which are recognised to affect outcomes 2 . Nevertheless approximately half of patients with NMDA-R antibody encephalitis do not respond adequately to first-line therapy, and a significant proportion (12-30%) relapse 2 . Cases A 19 year old lady presented with new-onset seizures and psychosis. EEG showed focal spike-and-wave discharges and MRI brain a focal area of restricted diffusion consistent with recent seizure activity. NMDA-R antibodies were present in both CSF and serum. Following early treatment with corticosteroid, plasma exchange, IVIG and rituximab the patient recovered, returning to college after 6 months.A 50 year old gentleman presented with a two day history of myalgias and confusion. EEG showed spike-and-wave discharges and MRI brain increased T2 signal in the mesial temporal lobes. NMDA-R antibodies were present in both CSF and serum. He was treated with corticosteroid, plasma exchange, IVIG and rituximab, and continued on oral prednisone and mycophenolate. Response to treatment was poor with persistent ongoing physical and cognitive impairment at 6 months. Serial MRI showed substantial (~30%) loss of parenchymal brain volume. Discussion These cases illustrate that timely and aggressive management of NMDA-R antibody encephalitis with favourable prognostic markers is no guarantee of recovery. Several novel clinical and immunological predictors of response to therapy have been postulated, and currently await broader validation. 3
ObjectivesTo present a case of bilateral thalamic ischaemic strokes in an elderly gentleman due to occlusion of the artery of Percheron, a rare anatomical variant in which a single branch of the posterior cerebral artery supplies the paramedian thalami bilaterally, as well as parts of the rostral brainstem and anterior thalamus.1MethodsA retrospective case review was performed of a patient diagnosed with artery of Percheron occlusion causing bilateral thalamic ischaemic strokes to demonstrate the clinical and radiological features of this unusual syndrome.CaseAn elderly gentleman presented to the emergency department after developing slurred speech and collapsing at home. His level of consciousness was fluctuating with a Glasgow Coma Scale score ranging from 3 to 9 (E1, V2, M6) and his pupils were reactive but unequal. Subsequently he was noted to have vertical gaze palsy and profound short term memory impairment. Initial CT imaging including a CTA was unremarkable. An MRI brain demonstrated bilateral medial thalamic infarcts suggestive of occlusion of the artery of Percheron. The clinical features fitted with the triad of vertical gaze palsy, memory impairment and coma described in previous cases of artery of Percheron occlusion.2 The patient was subsequently diagnosed with infective endocarditis with four sets of blood cultures positive for Staphylococcus capitis. A transoesophageal echocardiogram demonstrated multiple vegetations on his bioprosthetic aortic valve and a bone scan was suggestive of C5/6 discitis. Despite treatment, he later developed further areas of infarction in the basal ganglia and right parieto-occipital cortex. His condition eventually stabilised and he was discharged to a rehabilitation unit.ConclusionsThe artery of Percheron is a rare anatomical variant of the posterior cerebral circulation, occlusion of which causes bilateral thalamic ischaemic strokes. This is characterised by the clinical triad of vertical gaze palsy, memory impairment and coma.
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