What is the recommended investigation and management for a young individual who has experienced a stroke?

Stroke Workup in Young Individuals

Immediate Emergency Assessment

Young stroke patients require immediate brain imaging with non-contrast CT to exclude hemorrhagic stroke, followed by comprehensive "heart to head" diagnostic evaluation targeting unique etiologies not commonly seen in older adults. 1

Initial ED Evaluation (First 30 Minutes)

• Perform rapid assessment of airway, breathing, and circulation with neurological examination using NIHSS to determine stroke severity 2
• Obtain non-contrast head CT immediately to differentiate ischemic from hemorrhagic stroke—approximately 55% are ischemic and 45% hemorrhagic in patients under 50 years 1, 3
• Check vital signs including heart rate/rhythm, blood pressure, temperature, oxygen saturation, and assess for seizure activity 2
• Draw acute blood work including electrolytes, glucose, complete blood count, coagulation studies (INR, aPTT), and creatinine—but do not delay imaging or treatment 2

Vascular Imaging (Within Hours)

• Obtain CTA or MRA of both neck and intracranial vessels from arch-to-vertex to identify arterial dissection, vasculopathy, or large vessel occlusion 1
• Include MRV in both hemorrhagic and ischemic presentations, as 10% of hemorrhages in young patients are secondary to cerebral venous sinus thrombosis 1
• Perform fat-saturated T1 imaging of the neck to detect extracranial arterial dissections—a leading cause of stroke in young adults 1
• Consider conventional angiography when MRA is negative but clinical suspicion remains high, particularly for posterior circulation dissections 1

Acute Treatment (Time-Dependent)

For Ischemic Stroke

• Administer intravenous alteplase within 4.5 hours of symptom onset for eligible patients using the same criteria as older adults 1, 4
• Perform mechanical thrombectomy for large vessel occlusions within 24 hours of last known well 1
• Initiate LMWH or UFH pending completion of diagnostic evaluation—this differs from typical approach in older adults 1, 3

For Cerebral Venous Sinus Thrombosis

• Institute intravenous UFH or subcutaneous LMWH even with secondary hemorrhage, followed by warfarin for 3-6 months 1

Comprehensive Cardiac Evaluation

• Perform transthoracic echocardiogram with bubble study (agitated saline contrast) to detect patent foramen ovale and right-to-left shunts 1, 5
• Obtain transesophageal echocardiography for patients with suspected cardioembolic stroke and normal neurovascular imaging 1
• Use continuous telemetry monitoring during hospitalization, with prolonged ECG monitoring for at least two weeks in patients aged ≥55 years with embolic stroke of undetermined source to detect paroxysmal atrial fibrillation 1

Specialized Laboratory Testing

Young stroke patients require evaluation for unique etiologies including thrombophilia, coagulopathies, and metabolic disorders. 3

Hypercoagulable Workup

• Obtain antiphospholipid antibody panel, protein C, protein S, and antithrombin III levels to evaluate for thrombophilia and coagulation disorders 1
• Measure homocysteine level, as hyperhomocysteinemia increases stroke risk by 59% for every 5 μmol/L increase 1
• Consider sickle cell screening in relevant populations 5, 4

Additional Testing

• Check lipid panel, hemoglobin A1c, TSH, ESR, CRP, RPR, HIV, and toxicology screen 4
• Obtain blood cultures or lumbar puncture when infection is suspected 4

Secondary Prevention Strategy

Antithrombotic Therapy (Etiology-Specific)

• Use anticoagulation with warfarin (INR 2.0-3.0) for arterial dissection, cardioembolic sources, or antiphospholipid syndrome 1, 6
• Use antiplatelet therapy (aspirin or clopidogrel) for non-cardioembolic causes 1, 3
• Note that Asian patients and elderly may require lower warfarin doses to achieve therapeutic INR 6

Risk Factor Management

• Implement aggressive blood pressure control with target <140/90 mmHg (or <130/80 mmHg in selected patients) 1
• Achieve optimal glucose control in diabetic patients 1
• Initiate statin therapy as recommended for most stroke patients 4

Hyperhomocysteinemia Management

• Administer folic acid, vitamin B12, and vitamin B6 to reduce homocysteine levels 1
• For MTHFR 677TT genotype, use 5-methyltetrahydrofolate (5-MTHF) instead of folic acid 1
• B-vitamin supplementation may reduce stroke risk by 18-25% in patients with hyperhomocysteinemia 1

Rehabilitation and Long-Term Management

Acute Phase Interventions

• Begin comprehensive rehabilitation with multidisciplinary team approach in the acute phase 1, 5
• Perform dysphagia screening before oral intake to prevent aspiration pneumonia 1, 3
• Use venous thromboembolism prophylaxis with intermittent pneumatic compression devices or pharmacological prophylaxis for immobile patients 1
• Implement early mobilization with shorter, more frequent sessions rather than prolonged activity 1

Psychosocial and Vocational Support

• Assess vocational interests (work, school, volunteering) early in the rehabilitation phase for patients <65 years 1
• Perform detailed cognitive assessment including neuropsychological evaluation to assist in vocational planning 1
• Provide psychological support for unique challenges young survivors face with identity, career, and family responsibilities 1, 3

Follow-Up Monitoring

• Perform regular follow-up assessments to monitor for recurrent stroke, which occurs in 10-25% of young stroke patients 1, 3
• Obtain repeat neuroimaging to confirm vessel recanalization or detect recurrence in cerebral venous sinus thrombosis 1
• Continue ongoing assessment of educational needs for school-age stroke survivors 1

Critical Pitfalls to Avoid

• Inadequate long-term follow-up—young patients have longer life expectancy and therefore higher lifetime risk of recurrence 3
• Overlooking psychosocial impact on education, career development, and family planning 3
• Failing to investigate for arterial dissection with fat-saturated neck imaging 1
• Missing cerebral venous sinus thrombosis by not obtaining MRV 1
• Delaying anticoagulation in cerebral venous thrombosis despite presence of hemorrhage 1