Stroke in Young Adults: Occurrences on the Rise

Radiologists play a key role in accurate diagnosis to ensure immediate treatment

Ali Shaibani, MD
 Jennifer McCarty, MD

Physicians often diagnose an ischemic infarction in adults over the age of 55. Stroke is the fifth leading cause of death and disability in the U.S., and the vast majority (87%) are ischemic. However, just 10% to14% of strokes occur in adults between 18 and 45.

"Seeing a patient under 40 with a stroke is relatively unusual," said Ali Shaibani, MD, chief of neurointerventional radiology and professor of radiology at Northwestern University (NWU) Feinberg School of Medicine in Chicago.

Although the cause is unknown, the incidence of stroke in young adults has been increasing in recent years. In a RadioGraphics review, Jennifer McCarty, MD, reported that ischemic stroke in young adults is emerging as a public health issue and one in which radiologists can play a key role.

"When most people think of stroke, they think of older patients with risk factors like atherosclerotic disease, a history of smoking or chronic issues," said Dr. McCarty, a neuroradiologist and associate professor at McGovern Medical School, part of UTHealth in Houston (UT Houston)." But when we think of young adults, all of that shifts.”


"We're more likely to miss stroke in this population. If you're not looking for a stroke, you may not see it."


Stroke Risk Factors for Young Adults

"Young people don't have the typical chronic large or small vessel disease that we see in older patients," Dr. McCarty said. "It's more likely a cardioembolic clot, which is the number one cause by far, or an acute problem with the blood vessel."         

Compared to older adults, adults between 18 and 45 have more strokes from a cardioembolic clot (up to 46%), dissection, vasculitis and vasospasm. Dr. McCarty said specific populations, including patients with certain heart conditions and those with hypercoagulable and prothrombotic conditions, are also at increased risk for stroke.           

"Dissection is interesting because there are a lot of different causes, from major or minor traumas to an underlying vascular problem," she said. "We have also seen young adults with unusual and uncommon dissections associated with yoga, a chiropractic adjustment and even golf."          

Although individuals who live sedentary lifestyles early in life are more at risk for the large and small vessel occlusions that affect older adults, it's one of the lesser causes of stroke among young adults.        

"We do see younger adults with ischemic stroke who have had diabetes from a young age and a long history of smoking," Dr. Shaibani said.       

According to Dr. Shaibani, most patients have no risk factors for stroke at all.       

"We're more likely to miss stroke in this population," he said. "If you're not looking for a stroke, you may not see it.

Imaging for Young Adults With Suspected Stroke

Quickly diagnosing stroke is essential for younger patients because of the impact of a prolonged disability period on a career and family unit. A lack of a standard imaging protocol for stroke means protocols vary from institution to institution.      

Dr. Shaibani said most stroke centers perform a CT and CT angiography (CTA). NWU also performs perfusion imaging for all potential stroke patients regardless of the time of onset, although the guidelines don't require it within the first six hours.      

"The value of perfusion imaging is it shows areas not getting blood flow that can be missed on a CT angiogram," he said. "It prevents us from missing subtle occlusions not seen on CTA."      

At UT Houston, an initial clinical evaluation and CT have proven to be the fastest for the Emergency Department workflow; the use of perfusion imaging is at the discretion of the clinicians.      

"For our clinicians, it's about how fast can we determine whether there's a hemorrhage or not and if it's safe to treat them for an ischemic stroke," she said. "Getting patients to the angio suite or administering TPA/TNK quickly can make a huge difference in the outcome."

Dr. McCarty said some institutions have successfully implemented MRI into their stroke imaging protocol, which can be much better at evaluating posterior circulation infarcts that are small but have a big clinical impact.

Educating Young Adults About Signs of Stroke

Diagnosing stroke in young adults can be challenging because there isn't a classic presentation. Younger patients often present later in the course of the stroke because they are likely to brush off their symptoms, which can be vague, like nausea, vomiting, headache and dizziness. When they do present in EDs, they are frequently misdiagnosed and not always admitted.       

"It's absolutely critical to know the patient's clinical history and how serious the symptoms are," Dr. Shaibani said.        

One good clue of ischemic stroke in young adults is their ability to identify the onset of symptoms.        

"They normally can tell you the specific hour of the day their symptoms started," Dr. McCarty said. "There's not a lot that does that, besides the stroke."      

Promoting the acronym BEFAST (formerly FAST) to all ages will help both clinicians and the public consider the possibility of a stroke and the importance of acting quickly

  • Balance: (a hard time walking, dizziness)
  • Eyes (blurred vision, for example)
  • Face (one side is drooping, or it's hard to smile)
  • Arms (one arm is numb or hard to lift)
  • Speech (speech seems slurred, hard to understand)
  • Time (if any of these are present, it's time to call 911)

"A few decades ago, older adults received this messaging from multiple sources, and now they're much more likely to call 911 or go to the ED if they're experiencing symptoms," Dr. Shaibani said. "But young people aren't getting this message. We're at the same point with them as we were 15 years ago with older people."

For More Information

Access the RadioGraphics paper, “Ischemic Infarction in Young Adults: A Review for Radiologists.”

Read previous RSNA News articles on radiologist's role in evaluating stroke: