Stroke is one of the leading causes of death and permanent disability worldwide, posing significant public health challenges. People now recognise that younger adults can experience strokes, which were previously thought to affect only the elderly. Medical professionals define stroke in young adults as occurring in individuals aged 15 to 45 years. Although this age group has a lower incidence of stroke compared to older populations, the disease has major impacts because it strikes during prime working years, leading to widespread effects on society, mental health, and economic resources (1,2).

Every year around the world, nearly 12 million new stroke cases occur, and the condition remains one of the leading causes of death and disability-adjusted life years (DALYs). Research indicates that young adults account for approximately 10 to 15 percent of all stroke cases, and the number of cases has started to increase across multiple global regions (2,3). The demographic shifts in India, along with rising rates of vascular risk factors and the public's lack of knowledge about early stroke symptoms and risk factors, create a significant burden of stroke cases among younger people in low- and middle-income nations (4).

The causes of stroke in young adults show a completely different pattern from what doctors observe in elderly patients. This age group has multiple causes because traditional vascular risk factors like hypertension, diabetes mellitus, dyslipidemia, smoking, and obesity still serve as main risk factors for stroke (5). The cardioembolic sources include rheumatic heart disease, congenital heart disease, infective endocarditis, and atrial septal defects. Other causes include arterial dissections, vasculitides, hypercoagulable states, autoimmune disorders, oral contraceptive use, substance abuse, and genetic conditions (6,7). In developing countries, younger people can experience stroke from tuberculosis, HIV, and other infections which operate as risk factors (8).

Clinicians can observe three different types of stroke in young adults which include ischemic stroke and intracerebral hemorrhage and subarachnoid hemorrhage with ischemic stroke as the most prevalent form. The clinical manifestations depend on the vascular territory involved and may include sudden onset of weakness, speech disturbances, visual impairment, or altered consciousness (1). Young patients need early detection of their underlying cause because doctors can treat many conditions that lead to stroke, and prevention of future strokes constitutes the main treatment objective (6).

The problem has become more recognized by people but research about how young adults experience stroke in India remains extremely scarce. Effective diagnostic methods together with suitable management solutions and proper preventive strategies depend on understanding how demographic factors and risk factors and stroke causes affect this specific population. Therefore, the present study aims to evaluate the clinical profile and etiology of stroke in young adults aged 15–45 years admitted to a tertiary care centre

The present study was conducted in a tertiary care centre in Odisha over a period from September 2019 to October 2021. It was designed as a single-centre cross-sectional observational study including 75 patients diagnosed with stroke in the age group of 15–45 years. Patients presenting with a sudden onset of focal or global neurological deficit of vascular origin persisting for more than 24 hours were included in the study, while patients with recurrent stroke, head injury, transient ischemic attack (TIA), or intracranial space-occupying lesions were excluded.

After confirmation of diagnosis and eligibility, each patient underwent a detailed clinical evaluation, including comprehensive history-taking and thorough physical and neurological examinations. A series of laboratory investigations were performed, including complete blood count, lipid profile, liver function tests, fasting and post-prandial blood glucose, HbA1c, renal function tests, serum electrolytes, ESR, CRP, coagulation profile (PT, aPTT, INR), viral markers (HIV, HBsAg, HCV), and urine analysis.

Neuroimaging investigations such as non-contrast CT (NCCT) brain were performed initially to differentiate ischemic and hemorrhagic stroke, followed by MRI brain with MR angiography and MR venography when required to detect vascular occlusion or aneurysm. Cardiac evaluation with 2D echocardiography was done to identify potential cardioembolic sources such as rheumatic heart disease or intracardiac thrombus. Additional investigations, including abdominal and pelvic ultrasound, carotid Doppler, renal artery Doppler, cerebrospinal fluid analysis, protein C and S levels, antiphospholipid antibody profile, serum homocysteine levels, and sickling test, were carried out in selected cases based on clinical suspicion to identify underlying etiological factors. The severity of stroke was assessed using standardised scoring systems, including the Glasgow Coma Scale (GCS) for all patients, the National Institutes of Health Stroke Scale (NIHSS) for ischemic stroke, and the Intracerebral Haemorrhage (ICH) score for hemorrhagic stroke.

The collected data were coded and entered into Microsoft Excel for analysis, and the results were presented using appropriate tables and charts

Ethical Consideration

Before starting the study, approval was obtained from the research committee and ethical committee of SCB Medical College. The ethical approval proposal no is ECR/84/INST/OR/2013/RR-20. Consent was obtained from each participant, and assurance was given that confidentiality would be maintained in all aspects of the study.

Statistical Analysis

The collected data were entered into a Microsoft Excel sheet and analysed using SPSS version 26.0. Categorical data were represented as frequencies, percentages, and graphs. Continuous data were summarised as Mean ± Standard Deviation and Median (Range). P<0.05 was considered for statistical significance.

There are 75 study participants included in the study. The mean age of the participants is 36.146±8.155.  Table 1 displays the socio-demographic characteristics, type of stroke, comorbidities, and outcomes among these 75 young stroke patients. The majority of patients belonged to the 36–45 years age group, accounting for 45 cases (60%), followed by the 26–35 years group with 19 patients (25.3%), while the 15–25 years group consisted of 11 patients (14.7%), indicating that the occurrence of stroke increases with advancing age within the young adult population. In terms of gender, males and females were nearly equally represented, with 37 males (49.3%) and 38 females (50.7%), suggesting no significant gender dominance in this cohort. Regarding stroke type, ischemic stroke was the most common, seen in 50 patients (66.7%), while hemorrhagic stroke occurred in 25 patients (33.3%), also shown in Figure 1. Analysis of comorbidities revealed that rheumatic heart disease was the most frequent pre-existing condition, present in 22 patients (29.3%), followed by diabetes mellitus in 10 patients (13.3%), hypertension in 9 patients (12%), and chronic kidney disease in 3 patients (4%). Notably, 31 patients (41.3%) had no identifiable pre-existing medical condition, indicating that stroke can occur even without conventional risk factors in young adults. Regarding clinical outcomes, most patients had a favourable prognosis, with 62 patients (82.7%) discharged after treatment, while 13 patients (17.3%) died. This highlights that, despite occurring in a younger population, stroke still carries a significant risk of death.

Table 1: Socio-demographic Variables of study participants

Table 2 presents the etiological distribution of stroke among the study population and compares the causes between ischemic and hemorrhagic stroke patients. Among the 50 patients with ischemic stroke, the most common cause was cardioembolic disease, accounting for 23 cases (46%), highlighting the major role of cardiac disorders in the development of stroke in young adults. Diabetes mellitus was identified as the underlying etiology in 10 patients (20%), while protein C and S deficiency was observed in 5 cases (10%), indicating the contribution of hypercoagulable states to ischemic stroke. Tubercular meningitis accounted for 4 cases (8%), underscoring the importance of infectious causes in developing countries. Hyperhomocysteinemia accounted for 3 cases (6%), whereas vasculitis was found in 2 patients (4%). Less common etiologies included antiphospholipid antibody syndrome and sickle cell disease, each contributing to 1 case (2%). Only 1 ischemic stroke case (2%) had an unidentified cause. In contrast, among the 25 patients with hemorrhagic stroke, the most frequent cause was ruptured aneurysm, seen in 9 cases (36%), followed by chronic kidney disease in 6 patients (24%), which may predispose to vascular fragility and hypertension-related bleeding. Hypertension and renal artery stenosis each accounted for 4 cases (16%), highlighting their role in intracerebral hemorrhage among young individuals. Unknown causes were reported in 2 hemorrhagic stroke cases (8%). When considering the overall distribution among all 75 patients, cardioembolic causes constituted the largest proportion (30.7%), followed by ruptured aneurysm (12%), diabetes mellitus (13.3%), chronic kidney disease (8%), and protein C and S deficiency (6.7%), while other etiologies such as hypertension, tubercular meningitis, renal artery stenosis, hyperhomocysteinemia, vasculitis, antiphospholipid antibody syndrome, and sickle cell disease accounted for smaller proportions. These findings emphasize that the etiology of stroke in young adults is diverse and differs between ischemic and hemorrhagic stroke, with cardioembolic and hematological disorders predominating in ischemic stroke and structural vascular lesions and systemic diseases playing a major role in hemorrhagic stroke.

Table 2: Aetiology of Stroke In Young Stroke Patients

Table 3 and Figure 2 describe the clinical profile of young stroke patients and compare the presenting features between ischemic and hemorrhagic stroke. Motor deficit was the most common clinical manifestation, observed in 73 patients (97.3%) overall, including 48 patients (96%) with ischemic stroke and all 25 patients (100%) with hemorrhagic stroke, indicating that limb weakness was the predominant presenting symptom in both stroke types. Sensory deficit was present in 22 patients (29.3%), with a higher frequency in ischemic stroke (18 patients, 36%) compared to hemorrhagic stroke (4 patients, 16%). Altered sensorium was noted in 29 patients (38.7%) overall, but it was significantly more common in hemorrhagic stroke (19 patients, 76%) than in ischemic stroke (10 patients, 20%), suggesting a greater severity of neurological impairment in hemorrhagic cases. Cranial nerve involvement was seen in 12 patients (16%), including 9 cases (18%) of ischemic stroke and 3 cases (12%) of hemorrhagic stroke. Speech abnormalities such as dysarthria or aphasia were observed in 19 patients (25.3%), occurring more frequently in ischemic stroke (17 patients, 34%) compared to hemorrhagic stroke (2 patients, 8%). Seizures were reported in 20 patients (26.7%) overall, with a markedly higher occurrence in hemorrhagic stroke (14 patients, 56%) than in ischemic stroke (6 patients, 12%), reflecting the increased likelihood of cortical irritation and raised intracranial pressure in hemorrhagic events. Overall, these findings demonstrate that while motor weakness was the most common presentation in both stroke types, features such as altered sensorium and seizures were more frequently associated with hemorrhagic stroke, whereas sensory deficits and speech abnormalities were more commonly observed in ischemic stroke among young adults.

Table 3-Clinical Profile Of Stroke In Young Stroke Patients

Table 4 presents the severity grading of stroke among the study participants using the Glasgow Coma Scale (GCS) for all patients, the ICH score for hemorrhagic stroke patients, and the NIH Stroke Scale (NIHSS) for ischemic stroke patients. Based on the GCS score among all 75 young stroke patients, the majority of patients had moderate impairment, with 36 patients (48%) scoring between 9–12, followed by 29 patients (38.7%) with severe impairment (score 3–8), while only 10 patients (13.3%) had mild impairment with scores between 13–15, indicating that a substantial proportion of patients presented with significant neurological compromise, also represented in Figure 3. Among the 25 patients with hemorrhagic stroke, severity was assessed using the ICH score, where the majority had higher scores indicating more severe disease, with 14 patients (56%) having a score of 3, 8 patients (32%) having a score of 2, and 3 patients (12%) having a score of 4, while no patients had scores of 0, 1, 5, or 6. This distribution suggests that most hemorrhagic stroke patients presented with moderate to severe intracerebral haemorrhage. For the 50 patients with ischemic stroke, severity assessment using the NIHSS score showed that the majority had moderate stroke severity, with 37 patients (74%) scoring between 5–15, followed by 8 patients (16%) with scores between 16–20, indicating moderately severe stroke. A smaller proportion had mild stroke, with 2 patients (4%) scoring between 1–4, while 3 patients (6%) had very severe stroke with scores between 21–42, and none had a score of 0. Overall, these findings indicate that most young stroke patients in the study presented with moderate neurological severity, though a considerable proportion had severe impairment, particularly among those with hemorrhagic stroke

Table 4-Severity Grading Of Stroke In Young Stroke Patients

The etiology and site of stroke varies with different communities. Statistical data on the aetiology and site of strokes with proper correlation with brain imagery is still scanty for the Indian population.

In a study in 1997 by Nayak et al (9),177 patients with first ever ischemic stroke (age group 15–45 years) were included retrospectively based on hospital data, with 76% male and 24% female patients. In the current study, of the total 75 patients, males were 37 (49.3%) and females 38 (50.7%). Male to female ratio is nearly 1:1. In the current study, most common age group was 36 to 45 years (60%) followed by 66-35 years (25.3%).

In a study by Seyedhossein Ojaghihaghigh et al. (10), 503 patients were included. The diagnosis was hemorrhagic stroke in 144 patients and ischemic stroke in 359 patients. According to GCS records, the mean GCS (SD) score in ischemic stroke patients was 12.67 (0.81); however, the minimum score was 7, and the maximum was 15. Though in hemorrhagic stroke patients, the mean (SD) GCS score was 8.97 (0.182), with minimum of 6 and maximum of 15 (independent sample test P<0.001).81 While in the current study, out of total 75 patients of young stroke 50 were ischemic stroke and 25 were hemorrhagic stroke that is 66.7% were ischemic and 33.3% were hemorrhagic. Ischemic stroke outnumbered hemorrhagic stroke.

In the current study, out of the total 75 patients, 36 patients (48%) presented with GCS between 9-12, followed by 29 patients (38.7%) who had GCS between 3-8 and 10 (13.3%) patients had GCS between 13-15. Out of the total 50 Ischemic young stroke patients, 30 patients (60%) presented with GCS between 9-12, followed by 13 patients (26%) who had GCS between 3-8, and 07 patients (14%) who had GCS between 13-15. In the current study, out of a total of 25 hemorrhagic young stroke patients, 16 patients (64%) presented with GCS between 3-8, followed by 06patients (24%) who had GCS between 9-12, and 03 patients (12%) who had GCS between 13-15. In the study, among ischemic stroke patients, the minimum GCS at presentation was 6, the maximum was 14, and the mean was 9.62 ± 1.99. In hemorrhagic stroke, the minimum GCS at presentation was 3, the maximum was 14, and the mean was 8 ± 2.65.

While data from several western studies indicate that 21–48% of strokes in the young are caused by atherosclerotic large artery occlusive disease, 10–33% are due to non-atherosclerotic large artery occlusive disease ( dissections have comprised 10–20% in some studies), 13–35% are caused by cardioembolism, 3– 18% by penetrating artery disease, 8–15% by prothrombotic states and 4–15% by miscellaneous causes. Cryptogenic stroke comprises 7–40% of the cases.(11)

In the current study, out of 75 young stroke patients, the most common aetiology was RHD, cardioembolic stroke, i.e. 23 patients (30.7%), followed by diabetes mellitus,10 patients (13.3%).Out of 50 ischemic young stroke patients, the most common aetiology was  RHD, cardioembolic stroke, i.e.  23  patients (46%),followed by diabetes mellitus,10 patients (20%). Similarly, out of 25 hemorrhagic young stroke patients most common etiology was rupture aneurysm 9 patients (36%) followed by CKD 6 patients (24%); renal artery stenosis 4 patients (16%); hypertension 4 patients (16%);%),in 2 patient(8%) etiology was not known.

The ICH Score is a clinical grading scale composed of factors related to a basic neurological examination (GCS), a baseline patient characteristic (age), and initial neuroimaging (ICH volume, IVH, infratentorial/supratentorial origin). The purpose of this grading scale was to provide a standard assessment tool that can be easily and rapidly determined at the time of ICH presentation, even by physicians without special training in stroke neurology and that will allow consistency in communication and treatment selection in clinical care and clinical research. In an Indian study by Piyush Ojha et al., the maximum number of patients (n=40) had an ICH score of 2, which was followed by patients with an ICH score of 0 (n=24),1 (n=24), 3(n=8), 5 (n=4) and 6 (n=4).(12)

In the current study, of the 25 hemorrhagic young stroke patients, 14 (56%) had an ICH score of 3; 8 (32%) had an ICH score of 2, and 3 (12%) had an ICH score of 4.

In a study by Umar Farooque et al. (13), the highest proportion (n=79/141, 56%) of stroke patients in this study reported poor NIHSS score, followed by less than one-third (n=41/141, 29.1%) with moderate score, and the least proportion (n=21/141, 14.9%) reported good NIHSS score. While in the current study, out of the total 50 ischemic young stroke patients, 37 patients (74%) had moderate stroke;8 patients (16%) had moderate to severe stroke;3 patients (06%) had severe stroke, and 2 patients (4%) had minor stroken,

The present study highlights that stroke in young adults is an important clinical problem with significant health implications. The majority of patients belonged to the 36–45 year age group, with an almost equal distribution between males and females. Ischemic stroke was found to be the predominant subtype compared to hemorrhagic stroke. Cardioembolic causes, particularly rheumatic heart disease, emerged as the most common etiology among ischemic strokes, while rupture aneurysm and hypertension-related conditions were important causes of hemorrhagic stroke. Motor deficit was the most common presenting clinical feature, followed by altered sensorium and seizures. Most patients had moderate stroke severity at presentation, and although the majority were discharged after treatment, a notable proportion of patients succumbed to the illness. These findings emphasize the heterogeneous etiology and clinical presentation of stroke in young adults and highlight the importance of early diagnosis, identification of underlying causes, and prompt management to reduce morbidity and mortality in this productive age group.

Limitations

The present study has certain limitations that should be considered while interpreting the findings. Firstly, the study was conducted at a single tertiary care centre, which may limit the generalizability of the results to the wider population. Secondly, the sample size was relatively small (75 patients), which may not fully represent the complete spectrum of etiological factors and clinical presentations of stroke in young adults.

Recommendations

Based on the findings of this study, it is recommended that greater emphasis should be placed on early detection and management of risk factors for stroke in young adults, particularly rheumatic heart disease, diabetes mellitus, and hypertension. Routine evaluation for cardioembolic and hypercoagulable conditions should be considered in young stroke patients to identify potentially treatable causes. Strengthening preventive strategies, including early screening, public awareness regarding stroke symptoms, and prompt referral to tertiary care centres, can help reduce morbidity and mortality.

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