A stroke in a young adult should prompt a wider search for cause than in an older patient, because the mix of mechanisms differs and several are treatable or need specific secondary prevention.
Arterial dissection is a leading cause and is easy to miss, so include vessel imaging of the neck and head. Look for a cardioembolic source, including a patent foramen ovale where the stroke is otherwise unexplained, and consider atrial fibrillation with prolonged monitoring. Take a careful history for substance use, particularly stimulants, and for migraine, pregnancy and the puerperium, and hormonal contraception. Screen for the vascular risk factors that are increasingly present even in the young.
The habit worth keeping is to resist calling a young stroke cryptogenic until dissection, a cardiac source, substance use and a hypercoagulable state have been considered.
- Image the neck and head vessels to catch arterial dissection, a common young-stroke cause.
- Seek a cardioembolic source, including patent foramen ovale in otherwise unexplained stroke.
- Use prolonged rhythm monitoring to detect paroxysmal atrial fibrillation.
- Take a history for stimulant and other substance use, and for pregnancy and contraception.
- Do not label a young stroke cryptogenic before these are excluded.
Why it matters
The treatable causes of young stroke are the ones most easily missed by an older-patient workup.
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