Brain and blood vessels · For patients and doctors
A stroke or mini-stroke before the age of 50 is not just bad luck. It often has a cause that is different from the usual blood pressure, sugar and cholesterol, and finding it changes the treatment that prevents the next one. Enter what has been done so far. You see which causes have been checked, which tests are still missing and in what order, and what protects you now. Doctors get the cause category, the work-up against the guidelines, the RoPE score and PASCAL class for a hole in the heart (PFO), and treatment by cause.
Stroke symptoms now? Call 108 and go straight to a hospital with a 24-hour CT scan and a neurologist. Clot-dissolving treatment works only in the first few hours. Do not wait to see if it passes, and do not come to a clinic first. Caspian Healthcare does not have a CT scan or an emergency department.
For after the emergency. Use this once the stroke has been diagnosed in hospital, to see what has been checked and what is still missing. It is a guide for you and your doctor, not a diagnosis. Nothing you enter leaves this page.
Not sure? It is written on the discharge summary as "infarct" or "ischaemic stroke" (blocked artery), "TIA", "CVT" or "cortical venous thrombosis" (vein), or "bleed", "haemorrhage" or "ICH".
Your health tick all that apply| Test | This patient | Why, and when |
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Generic names. Check the current guideline, the label and the patient's bleeding risk before prescribing. The neurologist and cardiologist decide closure and anticoagulation.
| Finding | Treatment | Evidence |
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In the Helsinki Young Stroke Registry (1,008 patients aged 15 to 49), the TOAST causes were: cardioembolism about 20%, small vessel disease about 14%, large artery atherosclerosis about 8%, other determined causes about 22% (cervicocerebral artery dissection was the commonest single cause, about 15% of all), and undetermined about 33%. Atherosclerosis and small vessel disease rise steeply after 40, so a stroke at 45 with diabetes and smoking is closer to an older person's stroke than one at 25. In Indian series, rheumatic heart disease, cerebral venous thrombosis (especially after delivery), tuberculous meningitis with vasculitis, and high homocysteine are more common than in Western data.
Confirm with CT or MR venography. Anticoagulate even when there is a venous haemorrhage: low molecular weight or unfractionated heparin, then warfarin (INR 2 to 3) or dabigatran (RE-SPECT CVT; ACTION-CVT supports DOACs), for 3 to 12 months; longer with a severe thrombophilia, antiphospholipid syndrome or a recurrence. Look for the trigger: oestrogen, pregnancy and the puerperium, dehydration, local infection, anaemia, autoimmune disease, myeloproliferative disease (JAK2 with high counts), PNH with haemolysis, cancer. Inherited thrombophilia testing is reasonable in CVT, unlike arterial stroke. Combined oestrogen contraception is contraindicated afterwards; a copper IUD or progestogen-only method is preferred. Future pregnancies need a plan with low molecular weight heparin around delivery.
A bleed in a young adult is a vascular malformation until proven otherwise, even with high blood pressure. CT or MR angiography first; if normal and the cause is still unclear (lobar bleed, no hypertension, under 45), a catheter angiogram (DSA), and MRI with susceptibility imaging for a cavernoma, repeated after the blood has cleared. Also check platelets and clotting, anticoagulant use, cocaine and amphetamines, pregnancy (eclampsia, RCVS), and venous thrombosis presenting as a bleed.
After 60, most strokes come from years of high blood pressure, diabetes, cholesterol and smoking narrowing the arteries. Under 50 these still matter, especially after 40, but many strokes come from somewhere else: a clot from the heart, a hole in the heart, a small tear in a neck artery, a blood that clots too easily, inflamed arteries, drugs or hormones. Each of these has its own treatment. That is why a young person needs more tests than an older person after a stroke.
Before birth, there is a small flap between the two upper chambers of the heart. In about 1 in 4 adults it never fully seals. This is a patent foramen ovale (PFO). Usually it does no harm. Rarely, a small clot from a leg vein passes through it to the brain. A bubble test (salt water shaken into tiny bubbles and injected into a vein during an echo) shows whether blood crosses. Closing the PFO with a small device through a vein in the leg lowers the chance of another stroke, but only in people in whom the PFO is likely to be the cause. The RoPE score and the PASCAL class help decide that.
A small tear in the inner wall of a neck artery lets a clot form, which can travel to the brain. It can follow a sudden neck movement, an injury or even a hard sneeze, and often causes neck pain or headache on one side. It usually heals in 3 to 6 months with a blood thinner. A repeat vessel scan shows the healing.
An autoimmune condition in which antibodies make the blood clot too easily, in arteries, veins and the placenta. It is one of the treatable causes of stroke in young people, especially women with miscarriages. The test must be positive twice, at least 12 weeks apart, because infections can cause a short-lived positive result. The treatment is warfarin, not the newer blood thinners.
"Cryptogenic" means no cause was found. About 1 in 3 young strokes stays cryptogenic even after every test. When the stroke looks like a clot from somewhere (not a small deep stroke) and the basic tests are all done and normal, doctors call it an embolic stroke of undetermined source (ESUS). A longer heart rhythm recording sometimes finds the answer later.
Found an error? Write to info@caspianhealthcare.in.
Medically reviewed by Dr. Mohammed Imran, MS, MCh (Neuro). Built by Dr. Khizer Hussain Junaidy, Diabetologist & Bariatric Physician, Telangana State Medical Council 04937. General information for patients of Caspian Healthcare: your own doctor's advice comes first.