Stroke in Young People

29 October is World Stroke Day. About 10-15 per cent of strokes occur in people aged 18 to 50. This proportion is increasing.

A study published in the journal Neurology in September 2026 examined strokes that occurred in the Cincinnati region of the United States from 1993 to 2020. Over this period, the stroke rate among people aged 20 to 54 almost doubled. The number of strokes per 100,000 people per year rose from 34 to 62. Almost all of the increase came from ischaemic stroke. Over the same period, the stroke rate among people aged 55 and over fell. Hypertension, diabetes and atrial fibrillation became increasingly common among young patients.

The causes of stroke in young people are similar to those in older people. Hypertension, smoking, obesity, diabetes, high cholesterol and physical inactivity are the most common causes of stroke. These factors now appear at earlier ages. Many young people do not know that their blood pressure is high, because they have never had it measured.

Some causes, however, are more common in young people. Foremost among them is dissection of the neck arteries. A dissection is a tear in the inner layer of the artery wall. A clot forms at the site of the tear and disrupts blood flow to the brain. It accounts for only about 2 per cent of all strokes. In young and middle-aged patients, however, it causes 10-25 per cent of strokes. It can develop after a traffic accident, a sports injury, sudden forceful neck movements or neck manipulation. Sometimes it occurs without any obvious strain. There is often first a one-sided neck pain or headache. On the same side, the eyelid may droop and the pupil may become smaller. The stroke may develop hours or even days after these symptoms.

Patent foramen ovale is another frequently discussed cause in young people. It is a small opening between the two upper chambers of the heart that has not closed after birth. It is present in about a quarter of the population and causes no problems in most people. However, it is found more often in young people with strokes of unknown cause. A clot coming from the veins can pass through this opening and reach the brain. Three large studies published in 2017 showed that closing this opening reduced the risk of a new stroke in selected patients.

Some factors are of particular importance in women. Migraine with aura roughly doubles the risk of ischaemic stroke. This risk rises further in combination with smoking and oestrogen-containing contraceptive pills. During pregnancy and the period after childbirth, both strokes due to arterial blockage and clots in the brain's veins are more common. Stimulants such as cocaine and amphetamines can cause stroke in both sexes. Rarer causes include clotting disorders, inflammation of the blood vessels and hereditary diseases such as CADASIL or Fabry disease.

An important problem with stroke in young people is delayed diagnosis. Neither the patient nor the doctor may think of stroke. In 2014, the records of more than 187,000 patients in the United States were examined. Up to 12.7 per cent of those admitted to hospital with stroke had been sent home from the emergency department with a different diagnosis in the previous 30 days. In those younger than 45, this likelihood was found to be about seven times higher. The patients who were misdiagnosed were most often those who presented with dizziness and headache. These patients were often diagnosed with an inner ear infection or migraine.

The symptoms of stroke do not change with age. Drooping of one side of the face, sudden weakness or numbness in an arm or leg, speech disturbance, sudden loss of vision and sudden loss of balance are the most important symptoms at any age. When these symptoms start suddenly, a health facility should be contacted whatever the person's age. Clot-dissolving treatment can be given to suitable patients within the first 4.5 hours. Removal of the clot through the blood vessel can be performed in selected patients up to 24 hours. Every minute counts.

In 2013, follow-up results were published for 959 people in the Netherlands who had a stroke between the ages of 18 and 50. About a quarter of those who had an ischaemic stroke died within 20 years. This rate is markedly higher than in the general population of the same age. Among survivors, invisible problems such as fatigue, depression, attention difficulties and inability to return to work are common. For this reason, the cause of stroke in a young patient must always be investigated in detail. When a cause is found, a new stroke can often be prevented.

A large proportion of strokes in young people are linked to preventable risk factors. Having blood pressure measured, stopping smoking, and keeping weight and blood sugar under control are recommendations that apply to young people too.

References

Ekker MS, Boot EM, Singhal AB, et al. Epidemiology, aetiology, and management of ischaemic stroke in young adults. Lancet Neurol. 2018;17(9):790-801.

Fisher ER, Ding L, Stanton RJ, et al. Stroke in the young: incidence, 30-day case fatality rates, and risk factors over time in a population-based study. Neurology. Published online September 23, 2026. doi:10.1212/WNL.0000000000218622

Debette S, Leys D. Cervical-artery dissections: predisposing factors, diagnosis, and outcome. Lancet Neurol. 2009;8(7):668-678.

Mas JL, Derumeaux G, Guillon B, et al. Patent foramen ovale closure or anticoagulation vs. antiplatelets after stroke. N Engl J Med. 2017;377(11):1011-1021.

Saver JL, Carroll JD, Thaler DE, et al. Long-term outcomes of patent foramen ovale closure or medical therapy after stroke. N Engl J Med. 2017;377(11):1022-1032.

Søndergaard L, Kasner SE, Rhodes JF, et al. Patent foramen ovale closure or antiplatelet therapy for cryptogenic stroke. N Engl J Med. 2017;377(11):1033-1042.

Schürks M, Rist PM, Bigal ME, Buring JE, Lipton RB, Kurth T. Migraine and cardiovascular disease: systematic review and meta-analysis. BMJ. 2009;339:b3914.

Newman-Toker DE, Moy E, Valente E, Coffey R, Hines AL. Missed diagnosis of stroke in the emergency department: a cross-sectional analysis of a large population-based sample. Diagnosis (Berl). 2014;1(2):155-166.

Rutten-Jacobs LCA, Arntz RM, Maaijwee NAM, et al. Long-term mortality after stroke among adults aged 18 to 50 years. JAMA. 2013;309(11):1136-1144.