BACKGROUND: Intracerebral hemorrhage (ICH) of undetermined etiology occurs infrequently in young and middle-aged adults. We hypothesized that slight decreases in coagulation factors and formation of less compact fibrin clots prone to faster lysis predispose to this type of ICH.
METHODS: We recruited 44 consecutive patients aged <50 years following ICH of unknown cause at least 3 months since the event. Subjects free of ICH (n = 47) matched for age, sex, BMI, and hypertension served as the control group. We assessed plasma fibrin clot permeability, turbidity and fibrinolytic capacity, along with thrombin generation, coagulation factors (F) II, FV, FVII, FVIII, FIX, FX, FXI, antithrombin, and fibrinolysis proteins.
RESULTS: ICH patients (median age 41 years, 45.5 % women) had 8.4 % lower FII (p = 0.0001) and 10.1 % lower FVII activity (p = 0.0003), 9.4 % higher antithrombin activity (p = 0.0004) and 13.5 % lower platelet count (p = 0.02). Other factors and thrombin generation did not differ between the two groups. The ICH survivors were characterized by impaired fibrin polymerization reflected by 10.1 % longer lag phase of the turbidimetry curve (p = 0.0002), decreased fiber density indicated by 11.8 % lower maximum absorbance (p = 0.004), as well as 11.1 % shorter clot lysis time (p = 0.014) and 10.0 % faster increase of maximal D-Dimer levels (p = 0.000001).
CONCLUSIONS: We demonstrated a prohemorrhagic fibrin clot phenotype, along with lower FII, FVII and higher antithrombin activity in adults below 50 years of age who suffered from ICH of unknown cause, which might indicate novel mechanisms contributing to ICH in younger individuals.

The condition known as Takayasu\'s disease or Takayasu\'s arteritis is a type of vascular inflammation that affects the large and medium arteries. It can lead to a reduction in blood flow to various parts of the body, and it can cause severe complications. Patients with this disease may not have specific symptoms, which can lead to their diagnosis not being confirmed. Takayasu\'s disease is believed to be a probable cause of stroke in young patients. Although stroke is a common cause of morbidity, it is usually not an initial presentation in Takayasu\'s disease. In this study, a young female with left-sided hemiparesis was diagnosed with Takayasu\'s disease after a clinical and angiographic examination.

Having a stroke at a young age has a huge socioeconomic impact. Data on the trends of stroke incidence in young adults from prospective population-based studies are scarce.
The aim of this study was to analyze the trends in stroke incidence in 15- to 54-year-old residents of Tartu, Estonia from 1991 to 2017.
Three population-based studies with identical study protocols determining the incidence of first-ever stroke have previously been conducted in Tartu, Estonia (1991-1993, 2001-2003, and 2013-2017). All residents of Tartu with first-ever stroke (ischemic stroke, spontaneous intracerebral hemorrhage, and subarachnoid hemorrhage) who were hospitalized to the Department of Neurology, Tartu University Hospital in respective study periods were included prospectively. Overlapping data sources for case ascertainment were used to include both hospitalized and non-hospitalized cases. Trends in first-ever stroke incidence in 15- to 54-year-old residents of Tartu were calculated and compared using rate ratio (RR).
Altogether 259 strokes were identified. From 1991 to 2017, the proportion of women increased from 38.3% to 43.6%. Mean age at onset in women decreased from 46.9 (standard deviation (SD): 7.3) to 42.6 (SD: 8.9). Overall crude incidence rates per 100,000 decreased significantly from 1991 to 2003 (from 57.2 (95% confidence interval (CI): 46.9-69.1) to 35.7 (95% CI: 25.7-48.3)); RR: 0.62 (95% CI: 0.44-0.89). While also present in women, the decrease was most notable in 45- to 54-year-old men (RR: 0.55 (95% CI: 0.30-0.99)). In 35- to 44-year-old men, the incidence rates decreased significantly from 2001 to 2017 (RR: 0.37 (95% CI: 0.14-0.99)).
The overall first-ever stroke incidence rates decreased from 1991 to 2003 and remained stable thereafter.

Stroke is a major cause of disability and mortality among the Nigerian general population and thought to be commoner after the fifth decade of life and usually driven by conventional risk factors which are mainly cardio metabolic. However, with the youthful population in a city such as Abuja, stroke could be a mode of presentation of HIV in young people who are also more sexually active. Methods. This is a case series, reporting four cases of HIV positive young Nigerians with stroke. Patients´ data were retrieved from ward admissions records. The patients here had their socio-demographic data taken. They had presented with documented varied clinical features including those suggestive of stroke, after which they had HIV screening done which returned positive. One thousand four hundred and eighty-seven (1487) patients, were admitted in the medical ward, over a three-year period. Female to male ratio of 1:1 in the HIV-positive group, with an age range of 32 to 42 years and an average age of 37.5 years. Stroke constituted 5.7% of all admissions, with stroke in the young accounting for 1.2%. Of all stroke cases, stroke in the young constituted 21.43%, with those who were HIV positive accounting for 4.8%. Young people with stroke should be offered an HIV screening test.

A 21-year-old man had a long-standing history of leg ulcers and hyperpigmention over the feet. Over a span of 8 months, he had an acute ischemic stroke followed by a basal ganglia hemorrhage. He was finally diagnosed with DADA2 syndrome after genetic sequencing. The implications of this new syndrome and its links to stroke in the young are presented in this article.

OBJECTIVE: To determine whether the intracerebral hemorrhage (ICH) score is accurate in predicting 30-day mortality in young adults, we calculated the ICH score for 156 young adults (aged 18-45) with primary spontaneous ICH and compared predicted to observed 30-day mortality rates.
METHODS: We retrospectively reviewed all patients aged 18-45 consecutively presenting to the University of Iowa from 2009 to 2019 with ICH. We calculated the ICH score and recorded its individual subcomponents for each patient. Poisson regression was used to test the association of ICH score components with 30-day mortality.
RESULTS: We identified 156 patients who met the inclusion criteria; mean± standard deviation (SD) age was 35±8 years. The 30-day mortality rate was 15% (n=24). The ICH score was predictive of 30-day mortality for each unit increase (p= 0.04 for trend), but the observed mortality rates for each ICH score varied considerably from the original ICH score predictions. Most notably, the 30-day mortality rates for ICH scores of 1, 2, and 3 are predicted to be 13%, 26%, and 72% respectively, but were observed in our population to be 0%, 3%, and 41%. An ICH volume of >30cc [relative risk (RR) 28, 95% confidence intervals (CI) 3-315, p=0.01] and a GCS score of <5 (RR 13, 95% CI 0.1-1176, p=0.01) were independently associated with 30-day mortality.
CONCLUSIONS: The ICH score tends to overestimate mortality in young adults. ICH volume and GCS score are the most relevant items in predicting mortality at 30 days in young adults.

OBJECTIVE: The baseline characteristics of patients with symptomatic carotid web (CaW) are unclear. We investigate demographic and cerebrovascular risk factors in patients with this overlooked stroke etiology.
METHODS: We identified consecutive patients diagnosed with symptomatic CaW at a comprehensive stroke center from July 2014-December 2018. These patients were matched at a 1:4 ratio (based on age and NIHSS scores) to create a control group of acute ischemic stroke (AIS) patients with non-CaW etiologies from the local GetWithTheGuidelines stroke database.
RESULTS: Thirty patients with symptomatic CaW were compared to 120 AIS patients with non-CaW etiologies. Symptomatic CaW patients were more likely to be female (73.3 vs. 44.2%; p = 0.004) and black (86.7 vs. 64.2%; p = 0.02). Symptomatic CaWs patients had a fewer absolute number of modifiable cerebrovascular risk factors (1.7±1.1 vs. 2.5±1.2; p = 0.002), lower rates of hypertension (43.4 vs. 63.3%; p = 0.04), and a more favorable lipid profile with lower average LDL (89.5±30.3 vs. 111.2±43.7 mg/dL; p = 0.01) and higher average HDL (47.9±11.3 vs. 42.2±13.8 mg/dL; p = 0.01) as compared to strokes with non-CaW etiology. Symptomatic CaW patients were more likely to have a large vessel occlusion (80.0 vs. 51.7%; p = 0.005), despite similar e-ASPECTS between the groups (8.1±2.1 vs. 8.3±2.2; p = 0.30). On multivariable analysis, symptomatic CaW was an independent predictor of independence at discharge (OR 3.72; 95%CI 1.27-10.94).
CONCLUSIONS: A gender and racial predilection of symptomatic CaWs may exist as females and blacks were were found to be more likely affected. Symptomatic CaW patients have a more benign cerebrovascular risk factor profile corroborating the proposed mechanism of local stasis and thromboembolism. Despite presenting more commonly with LVO, symptomatic CaW was associated with good functional outcome, warranting further studies.

BACKGROUND: Stroke incidence is reportedly increasing in younger populations, although the reasons for this are not clear. We explored possible reasons by quantifying trends in neurologically focused emergency department (ED) visits, classification of stroke vs. TIA, and imaging use.
METHODS: We performed a retrospective, serial, cross-sectional study using the National Hospital Ambulatory Medical Care Survey to examine time trends in age-stratified primary reasons for visit, stroke/TIA diagnoses, and MRI utilization from 1995 to 2000 and 2005-2015.
RESULTS: Five million eight hundred thousand ED visits with a primary diagnosis of stroke (CI 5.3 M-6.4 M) were represented in the data. The incidence of neurologically focused reason for visits (Neuro RFVs) increased over time in both the young and in older adults (young: + 111 Neuro RFVs/100,000 population/year, CI + 94 - + 130; older adults: + 70 Neuro RFVs/100,000 population/year, CI + 34 - + 108). The proportion of combined stroke and TIA diagnoses decreased over time amongst older adults with a Neuro RFV (OR 0.95 per year, p < 0.01, CI 0.94-0.96) but did not change in the young (OR 1.00 per year, p = 0.88, CI 0.95-1.04). Within the stroke/TIA population, no changes in the proportion of stroke or TIA were identified. MRI utilization rates amongst patients with a Neuro RFV increased for both age groups.
CONCLUSIONS: We found, but did not anticipate, increased incidence of neurologically focused ED visits in both age groups. Given the lower pre-test probability of a stroke in younger adults, this suggests that false positive stroke diagnoses may be increasing and may be increasing more rapidly in the young than in older adults.

Antiphospholipid syndrome (APLS) is characterized by recurrent thrombosis. We report the case of a 36-year-old male who had acute right-sided ischemic stroke and right leg ischemia secondary to left ventricular (LV) thrombus caused by primary APLS. The literature review suggested that the LV thrombus presented most commonly with systemic embolism and was associated with a mortality rate of 22.2% with treatment. Thrombophilic workup in young patients with a systemic thromboembolic episode (s) is advised.

BACKGROUND: The incidence and prevalence of stroke among the young are increasing in the US. Data on healthcare utilization prior to stroke is limited. We hypothesized those < 45 years were less likely than those 45-65 years old to utilize healthcare in the 1 year prior to stroke.
METHODS: Patients 18-65 years old who had a stroke between 2008 and 2013 in MarketScan Commercial Claims and Encounters Databases were included. We used descriptive statistics and logistic regression to examine healthcare utilization and risk factors between age groups 18-44 and 45-65 years. Healthcare utilization was categorized by visit type (no visits, inpatient visits only, emergency department visits only, outpatient patient visits only, or a combination of inpatient, outpatient or emergency department visits) during the year prior to stroke hospitalization.
RESULTS: Of those 18-44 years old, 14.1% had no visits in the year prior to stroke compared to 11.2% of individuals aged 45-65 [OR = 1.30 (95% CI 1.25,1.35)]. Patients 18-44 years old had higher odds of having preventive care procedures associated with an outpatient visit and lower odds of having cardiovascular procedures compared to patients aged 45-65 years. Of stroke patients aged 18-45 and 45-65 years, 16.8 and 13.2% respectively had no known risk for stroke.
CONCLUSIONS: Patients aged 45-65 were less commonly seeking preventive care and appeared to be seeking care to manage existing conditions more than patients aged 18-44 years. However, as greater than 10% of both age groups had no prior risk, further exploration of potential risk factors is needed.