10-15% of stroke patients are young adults between 15-44 years old. Stroke risk factors for young adults include conditions like heart defects, recent pregnancy, smoking, drug use, and hypertension. The causes of stroke in young adults are more varied than in older adults and can include cardioembolic, atherosclerotic, and non-atherosclerotic vasculopathies as well as subarachnoid and intraparenchymal hemorrhages. Thorough investigations including imaging, blood work, and cardiac/vascular testing are important for determining the underlying cause, which often remains unknown in 20-30% of young stroke cases. Prognosis is generally better for young stroke patients compared to older patients

1. Stroke in Young Adults
Stroke in Young Adults

2. Epidemiology
10-15% of all Stroke patients
Among people 15 – 44 yo:
• 50% Ischemic Stroke
• 20% Intracerebral Hemorrhage
• 30% Subarachnoid
Hemorrhage
Increasing incidence of stroke in
younger age groups (Kissela et.
Al 2012)

3. Epidemiology

4. Epidemiology
• Racial and ethnic differences in stroke risk are even greater in younger populations
• Young blacks and Hispanics have a greater incidence of stroke than young whites (Jacobs et al.)
• Young black adults had a significantly higher hospitalization rate for stroke than whites and
Hispanics (Pathak et al.)

5. Risk Factors
Ischemic stroke in children
• cardiac abnormalities
• vascular lesions (focal cerebral
arteriopathy)
• hematologic abnormalities
• infection
• head and neck trauma
• genetic conditions
Ischemic stroke in young adults
• vasculopathy (ie. arterial dissection)
• cardiac defects
• recent pregnancy
• hypercoagulable states
• smoking
• illicit drug use
• premature atherosclerosis
• hypertension
• low physical activity
• metabolic disorders
• Migraine (possibly)

6. Modifiable Risk Factors
• Modifiable risk factors are the same for both younger and older
age groups.
• Prevalence of these risk factors not the same
• Hypertension, heart disease (including A fib), and diabetes
mellitus are the most common risk factors among the elderly.
• In contrast, among 1,008 young stroke patients in Finland, the
most common vascular risk factors were dyslipidemia (60%),
smoking (44%), and hypertension (39%).
• Putaala et al: 3,944 young stroke patients in Europe.
• The three most frequent risk factors were current smoking (49%),
dyslipidemia (46%), and hypertension (36%).

7. Etiology
• Range of potential etiologies for stroke in young
adults is broader than that for older adults
• Categorized as Ischemic or Hemorrhagic
• Ischemic includes Cardioembolic,
Atherosclerotic disease, and Non-
atherosclerotic vasculopathies
• Hemorrhagic includes Subarachnoid and
Intraparenchymal types

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13. Etiology
• Majority of teenage stroke patients have
undetermined etiology
• May be due to insufficient extent and timing of
the investigations.
• Younger patients are less likely to utilize 911
and do not appreciate they are at risk of
stroke.
• Diagnosis is often delayed or missed because
stroke is still considered a disease of the
elderly
• Also could be due to the way TOAST trial
classified etiologies

14. Clinical Manifestations
Symptoms often similar to stroke in older patients
Neurological symptoms localization to the brain
Focal manifestations
• Hemiparesis and hemifacial weakness in 67 to 90 percent
• Speech or language disturbance in 20 to 50 percent
• Visual disturbance in 10 to 15 percent
• Ataxia in 8 to 10 percent
Non-localizing manifestations
• Headache in 20 to 50 percent
• Altered mental status in 17 to 38 percent
• Vomiting in approximately 10 percent

15. Physical Exam
• Thorough Neuro Exam
• PE should also include dermatological and ophthalmologic assessment
Ophthalmologic Exam:
• Corneal arcus (hypercholesterolemia)
• Corneal opacity (Fabry’s disease);
• Lisch nodules, optic atrophy
(neurofibromatosis)
• Lens subluxation (Marfan’s,
homocystinuria)
Dermatologic Exam:
• Splinter hemorrhages or needle tracks
(endocarditis)
• Xanthoma (hyperlipidemia)
• Cafe-au-lait spots, neurofibromas
(neurofibromatosis)
• Purpura (coagulopathy)
• Capillary angioma (cavernous malformations)

16. Investigations
• Emergent treatment of younger stroke patients same as older patients
• Physiologic management:
• blood pressure, temperature, glucose, and oxygenation, and potential thrombolysis
• CT Head – initial imaging
• High sensitivity for acute hemorrhage
• CTA Head and Neck
• Most patients should get MRI
• DWI: very sensitive for acute ischemia
• TTE w/ bubble study
• Telemetry Monitoring
• Blood work: lipid panel, hemoglobin A1c, TSH, ESR, CRP, RPR, HIV, and
toxicology screen

17. Investigations
• When appropriate, SCD screen and pregnancy test
• Low threshold to obtain blood cultures or a lumbar puncture.
• indicated for cases suspicious for infectious, vasculitic, or occult hemorrhage origins.
• Toxicologic studies are useful, even when drug use is not acknowledged.
• Other blood tests may include:
• Hypercoagulable labs, fibrinogen, ANA, serum protein electrophoresis, hemoglobin electrophoresis.
Cause of stroke in young patients may remain
undetermined in 20% - 30% of cases

18. Prognosis
• Better outcomes
• 330 patients with first stroke or TIA (followed for an average of 96 months)
• 8% died, 3% had another stroke, and 3% had a myocardial infarction.
• Approximately 16% were dependent; 56% had returned to work.
• Only a minority of those who smoked at the time of their stroke subsequently stopped using
tobacco.
• The overall annual recurrence rate is less than 1%.
• Prognosis is often closely associated with the underlying cause