Etiologic spectrum in young ischemic strokes: Differences from the classical stroke paradigm and predominance of small vessel disease

Introduction: Ischemic strokes at a young age pose a significant clinical challenge because of their etiological diversity and risk profiles that differ from the classical stroke paradigm of the older population. This study aimed to evaluate demographic characteristics, risk factors, TOAST subtypes, and the etiologic spectrum, with attention to differences between the genders, in young ischemic stroke patients under 50 years of age.Methods: A total of 60 young ischemic stroke patients aged 18–50 years who were investigated and treated as inpatients in our clinic were included. The patients’ demographic data, stroke etiologies according to the TOAST classification, classical vascular risk factors (hypertension, diabetes, coronary artery disease, atrial fibrillation, smoking), arterial dissection, the presence of patent foramen ovale (PFO), and prothrombotic/vasculitis/genetic panel results were reviewed retrospectively.Results: The mean age of the patients was 39.45±6.37 years, and 73.3% (n=44) were men. According to the TOAST classification, 43.4% (n=26) of patients had small vessel disease, 20% (n=12) cryptogenic stroke, 16.7% (n=10) cardioembolic stroke, 15% (n=9) other causes such as vasculitis, dissection, or thrombophilia, and 5% (n=3) large artery atherosclerosis. Among vascular risk factors, smoking was present in 58.3%, hypertension in 45%, diabetes mellitus in 28.3%, coronary artery disease in 16.7%, and atrial fibrillation in 3.3%. The mean age of female patients (35.62±6.8) was significantly lower than that of male patients (40.84±5.7) (p=0.020). Arterial dissection was borderline more frequent in women (p=0.054), and no difference between the genders was found in admission NIHSS or discharge mRS scores.Discussion/Conclusion: In young ischemic strokes, the rare secondary causes such as dissection, vasculitis, and thrombophilia together account for only 15%, whereas the high prevalence of modifiable vascular risk factors (particularly smoking at 58.3% and hypertension at 45%) is noteworthy. The very low rates of atrial fibrillation (3.3%) and large artery atherosclerosis (5%), which make up the most common stroke etiologies in the older population, in our series support the marked predominance of small vessel disease (43.4%) in the young group and different pathophysiological processes. In conclusion, etiological investigations in the management of young stroke should not be limited to rare secondary causes; aggressive control of classical vascular risk factors should be a priority in primary and secondary prevention.Keywords: