Initial Workup for Stroke in Young Individuals
The initial workup for a young individual presenting with stroke must include immediate brain imaging with non-contrast CT or MRI, comprehensive vascular imaging from aortic arch to vertex, and targeted laboratory investigations to identify stroke etiology and guide treatment decisions. 1
Immediate Assessment (First 24 Hours)
Clinical Evaluation
- Rapid assessment of airway, breathing, and circulation 1
- Detailed neurological examination using standardized stroke scale (NIHSS or CNS) 1
- Assessment of vital signs: heart rate and rhythm, blood pressure, temperature, oxygen saturation, hydration status 1
Essential Imaging
- Non-contrast CT or MRI brain as soon as possible to rule out hemorrhage and identify acute ischemia 1
- Vascular imaging (CTA or MRA from aortic arch to vertex) to identify potential carotid stenosis, dissection, or other vascular abnormalities 1, 2
- Note: For posterior circulation strokes, follow-up MRI may be appropriate even when initial imaging is negative 1
Initial Laboratory Tests
- Complete blood count with platelet count
- Coagulation studies (INR, aPTT)
- Electrolytes, glucose
- Renal function tests (creatinine, eGFR)
- Cardiac markers (troponin)
- Toxicology screening (particularly cocaine and other drugs of abuse) 1
Cardiac Assessment
- 12-lead ECG to screen for atrial fibrillation and other cardiac conditions 1
- Consider early echocardiography, especially in young patients with cryptogenic stroke 1
Extended Workup (24-72 Hours)
Additional Vascular Assessment
- Consider conventional angiography if MRA/CTA results are inconclusive or if cerebral vasculitis is suspected 1
- For patients <50 years, evaluate for arterial dissection, particularly in the extracranial vessels 1, 3
Cardiac Evaluation
- Transthoracic echocardiography (TTE) to assess for cardiac sources of embolism
- Consider transesophageal echocardiography (TEE) in young patients with cryptogenic stroke to evaluate for:
- Patent foramen ovale
- Atrial septal aneurysm
- Left atrial appendage thrombus
- Aortic arch atheroma 1
Specialized Laboratory Testing
- Hypercoagulable state evaluation (particularly in patients <50 years) 1:
- Antiphospholipid antibodies
- Protein C, protein S, antithrombin III
- Factor V Leiden, prothrombin gene mutation
- Inflammatory markers (ESR, CRP) if vasculitis is suspected 1
- Consider genetic testing for monogenic causes of stroke when appropriate 1
Considerations Specific to Young Stroke Patients
Risk Factor Assessment
- Evaluate for traditional risk factors (hypertension, diabetes, smoking, dyslipidemia)
- Screen for substance abuse (particularly cocaine, amphetamines) 1
- Assess for oral contraceptive use in young women
- Consider rare causes more common in young patients:
Common Pitfalls to Avoid
- Delayed diagnosis: Young stroke patients are often misdiagnosed initially. Maintain high index of suspicion for stroke in young patients with focal neurological deficits 5
- Incomplete vascular imaging: Ensure imaging includes both intracranial and extracranial vessels 1
- Missing cardiac sources: PFO and other cardiac abnormalities are common causes of cryptogenic stroke in young patients 1
- Overlooking substance abuse: Toxicology screening is essential, as cocaine use increases stroke risk >6-fold in young adults 1
- Premature closure: Avoid concluding workup too early before considering rare causes common in young patients 4
Management Considerations
- Swallowing assessment before oral intake 1
- Seizure management if seizures occur at presentation 1
- Early mobilization when medically stable 1
- Temperature monitoring and management 1
- VTE prophylaxis with intermittent pneumatic compression devices and/or LMWH 1
By following this comprehensive approach to stroke workup in young patients, clinicians can identify the underlying etiology and implement appropriate secondary prevention strategies to reduce the risk of recurrent stroke, which occurs in 10-25% of young stroke patients 1, 6.