European Journal of Cardiovascular Medicine

Stroke is defined as a clinical syndrome characterized by rapidly developing neurological deficits focal or global lasting more than 24 hours or leading to death, caused by vascular events such as ischemia or hemorrhage.¹ While stroke has traditionally been considered a disease of older adults,it now affects 10–15% of individuals under 45 years,² driven by lifestyle changes, metabolic disorders, and improved diagnostics.³ The Global Burden of Disease Study 2020 shows rising incidence in young adults, especially in low- and middle-income countries with poor risk factor control. Rates vary geographically, from 5–15 per 100,000 in high-income countries to over 22 per 100,000 in LMICs.⁴ Urbanization, sedentary lifestyles, and increasing obesity, hypertension, and diabetes contribute to the growing burden of ischemic strokes in young populations.⁵

Clinically, young-onset stroke commonly presents with motor deficits, speech disturbances, visual impairment, and seizures. Ischemic strokes predominate, including cardioembolic, atherothrombotic, and cryptogenic subtypes, necessitating thorough etiological investigations. Hemorrhagic strokes, though less frequent, carry higher mortality and morbidity, often associated with hypertension, vascular malformations, or coagulopathies. Despite greater neuroplasticity in young adults leading to better recovery potential, risks of recurrent strokes, cognitive deficits, and psychological sequelae remain significant, emphasizing the need for rehabilitation and secondary prevention.^6-9

In India, stroke in young adults presents distinct challenges. Hospital admissions for young stroke account for 10–15% of cases, with modifiable risk factors such as smoking, dyslipidemia, hypertension, and diabetes being prevalent.^10,11 Additionally, India-specific etiologies such as cerebral venous sinus thrombosis, pregnancy-related strokes, and infections like tuberculosis contribute to the unique disease profile.¹² Socioeconomic consequences are substantial, with premature disability affecting both patients and their families. Despite the rising burden, comprehensive, region-specific data on young-onset stroke in India remain limited. Existing studies often focus on isolated risk factors or outcomes, while high rates of cryptogenic strokes (30–40%) indicate the need for advanced diagnostics and holistic analyses.^13-15 Hence the present study was undertaken to evaluate the clinical profile and risk factors associated with stroke in young patients less than 45 years. Stroke is defined as a clinical syndrome characterized by rapidly developing neurological deficits focal or global lasting more than 24 hours or leading to death, caused by vascular events such as ischemia or hemorrhage.1 While stroke has traditionally been considered a disease of older adults,it now affects 10–15% of individuals under 45 years,2 driven by lifestyle changes, metabolic disorders, and improved diagnostics.3 The Global Burden of Disease Study 2020 shows rising incidence in young adults, especially in low- and middle-income countries with poor risk factor control. Rates vary geographically, from 5–15 per 100,000 in high-income countries to over 22 per 100,000 in LMICs.4 Urbanization, sedentary lifestyles, and increasing obesity, hypertension, and diabetes contribute to the growing burden of ischemic strokes in young populations.5

Clinically, young-onset stroke commonly presents with motor deficits, speech disturbances, visual impairment, and seizures. Ischemic strokes predominate, including cardioembolic, atherothrombotic, and cryptogenic subtypes, necessitating thorough etiological investigations. Hemorrhagic strokes, though less frequent, carry higher mortality and morbidity, often associated with hypertension, vascular malformations, or coagulopathies. Despite greater neuroplasticity in young adults leading to better recovery potential, risks of recurrent strokes, cognitive deficits, and psychological sequelae remain significant, emphasizing the need for rehabilitation and secondary prevention.6-9

In India, stroke in young adults presents distinct challenges. Hospital admissions for young stroke account for 10–15% of cases, with modifiable risk factors such as smoking, dyslipidemia, hypertension, and diabetes being prevalent.10,11 Additionally, India-specific etiologies such as cerebral venous sinus thrombosis, pregnancy-related strokes, and infections like tuberculosis contribute to the unique disease profile.12 Socioeconomic consequences are substantial, with premature disability affecting both patients and their families. Despite the rising burden, comprehensive, region-specific data on young-onset stroke in India remain limited. Existing studies often focus on isolated risk factors or outcomes, while high rates of cryptogenic strokes (30–40%) indicate the need for advanced diagnostics and holistic analyses.13-15 Hence the present study was undertaken to evaluate the clinical profile and risk factors associated with stroke in young patients less than 45 years.

This was a hospital-based prospective observational study carried out in the Intensive Care Unit (ICU) and wards of the Medicine Department at a tertiary care center of central India over a period of 2.5years. A total of 100 patients aged 15–45 years with a confirmed diagnosis of stroke (ischemic or hemorrhagic) based on computed tomography (CT) and/or magnetic resonance imaging (MRI), presenting with abrupt onset of focal or global neurological deficits attributable to vascular causes and persisting for more than 24 hours, were included in the study. Patients or their relatives provided written informed consent for participation. Exclusion criteria included patients aged less than 15 years or more than 45 years, those who did not provide written consent for the study, and patients with neurological deficits resulting from head trauma. Detailed clinical history and repeated examinations were performed to document neurological deficits, stroke onset, affected brain regions, and risk factors such as hypertension, diabetes, smoking, alcohol, RHD, migraine, prior TIA, dyslipidemia, and coagulation disorders. Vital signs were recorded, and stroke severity was assessed using the NIHSS. Laboratory investigations included complete blood count, liver and kidney function tests, serum electrolytes, lipid profile, HbA1c, coagulation profile, blood culture, and CSF analysis when indicated. Imaging studies ultrasonography, 2D echocardiography, CT, MRI, DSA, and carotid Doppler were performed based on suspected etiology. Written informed consent was obtained from patients or their legally authorized representatives, and confidentiality was maintained. The study protocol was approved by the Institutional Ethics Committee. Data were compiled in Excel and analyzed to correlate clinical, laboratory, and imaging findings with stroke outcomes. Data Analysis Data were analyzed using SPSS software (version 25.0). Continuous variables, such as age, blood pressure, and laboratory values, were expressed as means with standard deviations, while categorical variables, including stroke type and presence of risk factors, were presented as percentages. The Kruskal-Wallis test was used to compare continuous variables across different groups, and Pearson’s chi-square test was applied for comparing categorical variables. A p-value of less than 0.05 was considered statistically significant.

A total of 100 patients aged 15–45 years (mean age 33.29 ± 10.01 years) were studied, with most in the 41–45-year group (31%) and a male predominance (57%). The mean height and weight were 162.56 ± 9.98 cm and 60.82 ± 11.78 kg, respectively, with a mean BMI of 22.96 ± 3.93 kg/m². Normal pulse rate was observed in 40%, normal respiratory rate in 49%, and normal blood pressure in 38% of cases. Pallor (20%) and pedal edema (18%) were the most common general findings. Cardiovascular examination showed normal S1 and S2 in 70% and 90% of patients, respectively, with murmurs in 14%. Tachypnea (57%) and aspiration (27%) were common respiratory findings, while abdominal examination revealed a non-palpable liver in all and splenomegaly in 2% of cases, (Table 1).

Table 1: Distribution of patients according to demographic profile, vital parameters, general and systemic examination findings

The most frequently observed presenting symptom was altered sensorium, reported in 70% of patients. Other common symptoms included vomiting (39%), headache (35%), seizures (34%), right hemiparesis (34%), and left hemiparesis (31%), (figure 1).

Figure 1: Clinical Presentation – Symptoms

Most participants had normal values for RBS (90%), HbA1c (75%), platelets (88%), MCV (63%), LDL (90%), total protein (78%), albumin (93%), bilirubin (90%), SGOT (88%), SGPT (92%), creatinine (76%), potassium (93%), magnesium (100%), and phosphate (89%). Abnormal values were more common in FBS (59% high), PPBS (47% high), hemoglobin (75% with mild to severe anemia), total cholesterol (76% low or high), triglycerides (73% low or high), HDL (60% abnormal), urea (51% high), sodium (39% low), calcium (39% low), uric acid (12% abnormal), and direct bilirubin (4% abnormal), (Table 2).

Table 2: Laboratory Parameters of Study Participants

Most participants had normal ECG (44%), 2D Echo (69%), and USG abdomen/pelvis (80%) findings. Abnormalities were observed in 56% of ECGs, including bradycardia (22%), tachycardia (34%), rhythm abnormalities (AFib, 9%), and chamber hypertrophy (LVH 21%, RVH 5%). In 2D Echo, 31% had abnormal findings: mitral valve disease (MS 9%, MR 6%, MVR 5%), aortic regurgitation (2%), tricuspid regurgitation (8%), RWMA (1%), prosthetic valve dysfunction (1%), infective endocarditis (2%), thrombus (4%), LVH with preserved EF (11%), LV systolic dysfunction (4%), pulmonary arterial hypertension (8%), and congenital heart disease (VSD with Eisenmenger 1%). USG abdomen/pelvis abnormalities were noted in 20%: small kidneys (7%), grade 1 renal parenchymal disease (4%), grade 2 renal disease (1%), liver parenchymal disease (2%), splenomegaly (1%), autosplenectomy (1%), cholelithiasis (1%), and moderate ascites (1%). Doppler studies  were performed in selected patients with suspected large vessel disease which  showed luminal stenosis in 7 participants (4% non-significant, 3% significant), and all 3 suspected participants undergoing DSA had abnormalities: large vessel stenosis (1), cerebral cavernous malformation (1), and left frontal pial arteriovenous fistula (1), (Table 3).

Table 3: Cardiac, Abdominal, and Neuroimaging Findings in Study Participants

Based on NIHSS score most patients had moderate (32%) or severe (34%) strokes, while 19% had minor strokes and 15% had moderate-to-severe strokes as depicted in figure 2. The most common type of stroke was infarct, accounting for 51% of cases. Hemorrhagic stroke was observed in 38% of patients. Less frequently, cerebral venous sinus thrombosis (CVST) was identified in 8%, and subdural hematoma (SDH) in 3%.

Figure 2: NIHSS Score

Mortality was highest in patients with severe anemia (<8 g/dL, 12/15, 75%), deranged kidney function (urea >40 mg/dL or creatinine >1.2 mg/dL, 12/19, 63.1%), and electrolyte abnormalities (50.8%), all showing significant associations (p<0.05). Patients with normal hemoglobin, kidney function, and electrolytes had higher discharge rates, e.g., normal hemoglobin 21/25 (84%), normal kidney function 57/81 (70.4%). Other parameters such as platelets, MCV, blood sugar, lipid profile, and liver function tests did not show statistically significant differences in outcomes., (Table 4).

Table 4: Laboratory parameters with outcome

Phosphate and creatinine emerged as significant prognostic markers, while calcium and uric acid showed a trend towards poor outcomes, as shown in table 5.

Table 5: Electrolytes with outcome

Mortality was highest in patients with cardiovascular bradycardia (16/25, 64%), respiratory tachypnea (35/57, 61.4%), and aspiration (22/27, 81.5%), all showing significant associations with poor outcomes (p<0.001). Patients with normal heart rate (31/36, 86.1%), normal sinus rhythm (32/48, 66.7%), absence of murmur (52/86, 60.5%), absence of tachypnea (42/43, 97.7%), and no aspiration (59/73, 80.8%) had higher discharge rates. ECG abnormalities such as sinus bradycardia, sinus tachycardia, and LVH did not show statistically significant impact on outcomes (p>0.05), (Table 6).

Table 6: Electrocardiographic, cardiovascular, and respiratory parameters with outcomes

Among 100 patients, ischemic strokes (61%) were more common than hemorrhagic strokes (39%). Highest mortality was observed in CKD-associated hypertension (71.5%) and rare hemorrhagic causes like thrombocytopenia and AML-induced DIC (100%). Most ischemic stroke patients had favorable outcomes, especially cardioembolic and pregnancy-related strokes (100% discharged). Undetermined etiology had moderate mortality (47.1%), (Figure 6).

Table 7: Etiology and outcome

Among 100 patients, rheumatic heart disease, past cerebrovascular events,  were associated with favorable outcomes. Chronic kidney disease (77.8%) and cancer history (100%) were linked to high mortality. Other risk factors, including hypertension, diabetes, alcohol use, and smoking, showed moderate influence on outcomes, (Table 7).

Table 8: Risk factors with Outcome

Mortality was highest in patients with severe stroke (NIHSS 21–42, 31/34, 91.2%), while patients with minor (0–4) and moderate (5–15) strokes had excellent survival rates (94.8% and 96.8% discharged, respectively). Moderate-to-severe strokes (16–20) had intermediate outcomes with 20% mortality. The association between NIHSS score and outcome was statistically significant (p<0.001), (Figure 3).

Mortality was highest in patients with overtherapeutic INR (>3.5, 1/1, 100%) and those on therapeutic anticoagulation for other indications (2/3, 66.7%). Patients not on anticoagulation, whether with normal (41/62, 67.2%) or prolonged INR (21/31, 67.7%), and those on therapeutic anticoagulation for mechanical valves (2/3, 66.7%) had comparatively lower mortality. Overall, differences were not statistically significant (p=0.505).

Figure 3: NIHSS score with Outcome

Multivariate analysis identified key independent predictors of mortality in stroke patients. Severe NIHSS score (>20) was the strongest, with 26-fold higher odds of death (p<0.001). Chronic kidney disease increased mortality over fivefold (p=0.002), and hypertensive emergency raised risk nearly five times (p=0.006). Tachypnea and low hemoglobin (<10 g/dL) also significantly elevated risk (2.9- and 3-fold, respectively; p<0.05). Tachycardia (>100 bpm) showed a twofold increased risk but was not statistically significant after adjustment (p=0.07). Overall, stroke severity, renal dysfunction, hypertensive crisis, anemia, and respiratory compromise were the strongest predictors of poor outcomes, (Table 9).

Table 9: Multivariate Logistic Regression Analysis of Factors Associated with Outcome

In the present study of 100 young stroke patients, the mean age was 33.29 ± 10.01 years with male predominance (57%). Hypertension (31%), alcohol use (27%), diabetes (8%), and smoking (2%) were the main risk factors, while laboratory and imaging revealed elevated HbA1c, low HDL, ECG LVH (21%), and echocardiographic LVH (13%). Cardioembolic sources, primarily rheumatic heart disease (14%), along with chronic kidney disease (9%), sickle cell disease (5%), and cancer (3%), contributed to morbidity, and anticoagulation therapy (theraupetic range)(20%) improved survival. Undetermined etiology was seen in 33.6% of cases.  These findings are consistent with previous Indian and global studies regarding demographics, risk factors, and etiological patterns.7,8,12

The clinical symptoms were severe, with altered sensorium (70%), seizures (34%), vomiting (39%), and hemiparesis (65%), with right hemiparesis linked to better survival and seizures/vomiting predicting mortality. Ischemic strokes predominated (51%), followed by hemorrhagic (38%) and CVST (8%), with 33.6% undetermined etiology. NIHSS scores indicated mostly moderate-to-severe strokes (81% >5). Systemic complications included tachycardia (36%), bradycardia (25%), tachypnea (57%), aspiration (27%), and anemia (Hb 10.50 ± 2.61 g/dL). These findings align with Indian studies showing high severity, ischemic predominance, and hemorrhagic burden.6,12,14,16, while Western cohorts report milder presentations.7,13,17

The current study showed frequent laboratory abnormalities, including anemia, hyperglycemia (HbA1c 7.21 ± 0.47%), low HDL, and deranged kidney function (19%, p=0.011), which predicted mortality. CSF analysis (n=8) suggested infectious etiologies like TBM. Cardiac evaluation revealed RHD and LVH (ECG 43%, ECHO 31%), highlighting cardiovascular risk. These findings align with Indian and global studies emphasizing metabolic, renal, and cardiac contributions to young stroke outcomes.18,19 Most patients had moderate-to-severe strokes (NIHSS ≥16 in 49%), with severe strokes (>20) in 34%. Right-sided hemiparesis favored survival. Compared to Western cohorts (median NIHSS 4–5, milder deficits), our findings mirror Indian data showing higher stroke severity and poorer functional status.12-14,16,20 Ischemic infarcts were most common (51%), followed by hemorrhagic strokes (38%), CVST (8%), and SDH (3%). Undetermined etiologies were frequent, and hemorrhagic strokes were often linked to hypertension or malformations. These distributions are consistent with previous Indian and Asian studies, though Western cohorts report lower hemorrhagic rates.7,8,13-15

In-hospital mortality was 36% with 64% discharge, higher than Western young stroke data (10–15%) but comparable to Indian reports (20–36%).9,13,14,16 Predictors of poor outcome included seizures, vomiting, bradycardia, tachypnea, and renal dysfunction, while anticoagulation and RHD were associated with better survival, consistent with global and Indian studies.9,13,19,21,22 Hypertension (31%) and diabetes (8%) were non-significant for mortality, unlike some Indian cohorts. Chronic heart disease (9%) and cancer (3%) predicted worse outcomes. Smoking (2%) and alcohol (27%) had no significant effect. Undetermined risk factors were common (20–40%), reflecting cryptogenic mechanisms reported previously.9,14,16 Bradycardia (25%) and tachypnea (57%) were strong mortality predictors, while aspiration (27%) paradoxically favored survival, possibly due to early detection or aggressive management. Dyslipidemia (11%) and liver dysfunction (10%) had no significant impact, whereas kidney impairment remained a strong predictor (p=0.011), corroborating Indian and global findings on renal risk in young stroke.18,23,24

In the present study, NIHSS scores strongly correlated with outcomes: patients with minor (0–4) and moderate (5–15) scores had high discharge rates (94.8% and 96.8%) and low mortality (5.2% and 3.2%), whereas moderate-to-severe (16–20) and severe (21–42) strokes had progressively worse outcomes, with mortality of 20% and 91.2% (p=0.0001), highlighting the prognostic utility of NIHSS. These findings indicate that higher scores reflect extensive neurological damage, large infarcts, or hemorrhagic strokes, often compounded by comorbidities like hypertension, diabetes, or heart disease, as well as complications such as aspiration or respiratory failure. The high discharge rates in minor and moderate groups suggest effective acute management and timely interventions, likely including thrombolysis or rehabilitation. The results are consistent with prior studies done by Putaala et al. (2009, 2012)1,13, Feigin et al2, Béjot et al4 and Tang et al.20 highlight poor outcomes in young adults with severe or hemorrhagic strokes, particularly when comorbidities or delayed treatment are present. These findings reinforce the importance of early NIHSS assessment for risk stratification, prompt intervention, and tailored rehabilitation.

Limitations of present study include hospital-based selection bias toward severe cases, a small sample size (n=100) limiting subgroup analysis, lack of long-term follow-up for recurrence or quality of life, and incomplete genetic or hypercoagulability testing, which may overestimate undetermined etiologies. Future research should adopt multicenter designs with advanced diagnostics (genetic screening, prolonged monitoring) and interventions targeting modifiable risks such as hypertension and dyslipidemia to reduce incidence. Our study illustrates the unique young stroke landscape in India: younger onset, higher hemorrhagic fraction, and elevated mortality from modifiable risks and cryptogenic causes. Compared to global patterns, Indian disparities demand enhanced awareness, early screening, and policy-driven prevention to curb this rising threat.

The present study highlights the clinical profile of stroke in young adults under 45 years. Ischemic stroke was the most common subtype, with a significant proportion remaining of undetermined etiology. Among identifiable causes, atherosclerosis, cardioembolism, and metabolic factors were prominent. Hemorrhagic stroke was the second most frequent subtype, most often associated with hypertension. High NIHSS score, hemodynamic instability (tachycardia, tachypnea, hypertensive emergency), low haemoglobin, and the presence of chronic kidney disease are significant independent predictors of poor outcome in stroke patients.

1.      Putaala J, Yesilot N, Waje-Andreassen U, et al. Demographic and geographic vascular risk factor differences in European young adults with ischemic stroke: The 15 Cities Young Stroke Study. Stroke. 2012;43:2624–30.

2.      Feigin VL, Forouzanfar MH, Krishnamurthi R, et al. Global and regional burden of stroke during 1990–2010: findings from the Global Burden of Disease Study 2010. Lancet. 2014;383(9913):245-55.

3.      Ramirez L, Kim-Tenser MA, Sanossian N, et al. Trends in acute ischemic stroke hospitalizations in the United States. J Am Heart Assoc. 2016;5(5).

4.      Béjot Y, Delpont B, Giroud M. Rising stroke incidence in young adults: more epidemiological evidence, more questions to be answered. J Am Heart Assoc. 2016;5(5).

5.      Kissela BM, Khoury JC, Alwell K, Moomaw CJ, Woo D, Adeoye O, et al. Age at stroke incidence increased stroke occurrence in young adults. Stroke. 2019;50(5):1252–8.

6.      Kapoor D, Dhiman A, Sharma R, Sundar S. Clinical profile, risk factors and aetiology of young stroke: A tertiary care hospital-based study from the Sub-Himalayan region in North India. Int J Res Med Sci. 2014;2:1355-9.

7.      Adams HP, Kappelle LJ, Biller J, et al. Ischemic stroke in young adults: Experience in 329 patients enrolled in the Iowa Registry of Stroke in Young Adults. Arch Neurol. 1995;52(5):491–5.

8.      Ruíz-Sandoval JL, Cantú C, Barinagarrementeria F. Intracerebral hemorrhage in young people: Analysis of risk factors, location, causes, and prognosis. Stroke. 1999 Mar;30(3):537-41.

9.      Lipska K, Sylaja PN, Sarma PS, Thankappan KR, Kutty VR, Vasan RS, Radhakrishnan K. Risk factors for acute ischemic stroke in young adults in South India. J Neurol Neurosurg Psychiatry. 2007 Sep;78(9):959-63.

10.   Yahya T, Jilani MH, Khan SU, et al. Stroke in young adults: Current trends, opportunities for prevention and pathways forward. Am J Prev Cardiol. 2020;3:100085.

11.   Divišová P, Šaňák D, Král M, et al. Young cryptogenic ischemic stroke: A descriptive analysis of clinical and laboratory characteristics, outcomes and stroke recurrence. J Stroke Cerebrovasc Dis. 2020;29:105046.

12.   Kumar NSS, Padala R, Vallampalli G, Thatikonda A, Prasad PNS. Clinical and etiological profile of ischemic stroke in young adults: A prospective, observational, hospital-based study from seacoast population of South India. Austin J Cerebrovasc Dis Stroke. 2017;4(1):1052.

13.   Putaala J, Metso AJ, Metso TM, et al. Analysis of 1008 consecutive patients aged 15 to 49 with first-ever ischemic stroke: The Helsinki Young Stroke Registry. Stroke. 2009;40:1195–203.

14.   Baghel PK, Singh K, Gupta CS. Study of stroke in young adults in Vindhya region. J Evol Med Dent Sci. 2020;9(12):991-4.

15.   Wasay M, Kaul S, Menon B, Venketasubramanian N, Gunaratne P, Khalifa A, et al. Ischemic stroke in young Asian women: Risk factors, subtypes and outcome. Cerebrovasc Dis [Internet]. 2010;30(4):418–22.

16.   Karri M, Ramasamy B. Risk factors, etiology, and clinical outcome of ischemic stroke in young adults admitted in a tertiary care hospital in India. J Stroke Med. 2019;2(1):32–9.

17.   Kristensen B, Malm J, Carlberg B, Stegmayr B, Olsson T. Epidemiology and etiology of ischemic stroke in young adults aged 18 to 44 years in northern Sweden. Stroke.1997;28(9):1702-1709.

18.   Putaala J, Haapaniemi E, Kaste M, Tatlisumak T. How does dyslipidemia predict stroke risk in young adults? Stroke. 2019;50(9):2381–8.

19.   Ropper AH, Samuels MA. Cardiology-related stroke mechanisms: A clinical approach. N Engl J Med. 2020;383(5):462–72.

20.   Tang M, Yao M, Zhu Y, Peng B, Zhou L, Ni J. Sex differences of ischemic stroke in young adults—A single-center Chinese cohort study. J Stroke Cerebrovasc Dis. 2020;29:105087.

21.   Ganesh NS, et al. Cardiogenic embolism in young stroke patients. J Stroke Med. 2019;15(2):78-84.

22.   Baddour LM, Wilson WR, Bayer AS, Fowler VG, Bolger AF, Steckelberg JM, et al. Infective endocarditis: Diagnosis, antimicrobial therapy, and management. Circulation. 2021;143(23):e963–78.

23.   Panwar Y, Shivde P, Piplewar P, et al. Aetiology, clinical profile and risk factors in young stroke in Central India. J Evid Based Med Healthc. 2019;6(40):2671-5.

Mokli Y, Pfaff J, Braun M, Simgen A, Meckel S, Radbruch A, et al. Infectious causes of ischemic stroke: A systematic review and meta-analysis. Stroke. 2021;52(3):992–1001.