Young-onset ischaemic stroke (YOIS), commonly defined as stroke occurring between 18–49 years, is increasing worldwide, particularly in low- and middle-income Asian countries, causing significant disability during productive years. [1–3]

Although conventional risk factors such as hypertension, diabetes, dyslipidaemia, and smoking remain important, non-atherosclerotic causes such as cervical artery dissection and cardioembolism, including PFO-related stroke, are also significant in young adults. [4–8]

In India, young stroke patients commonly have modifiable vascular risk factors, with varying contributions from cardioembolism, large-artery atherosclerosis, and undetermined causes. However, regional data remain limited, particularly in Andhra Pradesh. [9,10]

Delayed recognition and hospital arrival often limit access to timely reperfusion therapy, emphasising the need for awareness and improved stroke-care pathways. [11,12]

Guntur Government Hospital (GGH) serves a large urban and rural population, but current data on young-adult stroke in the region are limited. This study therefore aims to identify etiological patterns, modifiable risk factors, and functional outcomes in patients aged 18–40 years, providing evidence to improve diagnosis, secondary prevention, and stroke-care protocols in Andhra Pradesh.

AIMS & OBJECTIVES

• To evaluate the etiology and the risk factors of Ischemic Stroke in young adults.
• To study the different mode of clinical presentation of Ischemic Stroke in young adults.
• To study the pathogenesis of young stroke with the aid of nvestigations, treatment outcome and prognosis.
• Correlative study of the above modalities.

Study Design This study was designed as a prospective observational study conducted over a period of 12 months. Study Setting The study was carried out in the Department of General Medicine, Government General Hospital (GGH), Guntur, affiliated with Guntur Medical College, Guntur, Andhra Pradesh. Study Population and Sample Size Fifty people were included in the trial. All participants were young people aged 18 to 40 years, hospitalised with ischaemic stroke verified via clinical and radiological assessment. Inclusion Criteria Patients meeting the subsequent criteria were included: • Individuals aged 18 to 40 years. • Patients hospitalised in the General Medicine or Neurology departments exhibiting sudden onset of localised neurological deficits of vascular (ischaemic) aetiology lasting over 24 hours. Exclusion Criteria The subsequent patients were omitted from the research: • Women who are pregnant or within 30 days postpartum. • Patients under 18 years of age or over 40 years of age. • Individuals with cranial injuries, neurological infections, venous infarctions, central nervous system neoplasms, subdural haematomas, or hemorrhagic infarctions. Ethical Considerations The research commenced with the clearance of the Institutional Ethics Committee at Guntur Medical College, Guntur. Informed and written permission was acquired from all participants before their inclusion. The confidentiality of patient data was rigorously upheld. No physical harm or discomfort was inflicted onto any subject throughout the trial. Data Collection Upon acquiring consent, each subject had a comprehensive evaluation. A systematic case record form was utilised to document demographic information, clinical presentation, and risk variables. Comprehensive history taking, vital sign assessment, and systematic examination were conducted for all individuals. The obtained data were inputted into a Microsoft Excel spreadsheet for recording and analysis. Investigations All patients had pertinent laboratory and imaging examinations, which included: • Complete hemogram • Coagulation profile • Routine urine analysis • Blood sugar levels • Serum lipid profile • Serum electrolytes • Serum creatinine and blood urea • Viral screening • Serum homocysteine • Chest X-ray • ECG • CT Brain • MRI Brain / MR Angiogram / MR Venogram • Carotid Angiography • CSF Analysis • Supplementary tests, including the ANA profile and APLA (Antiphospholipid Antibody) panel, were conducted if clinically warranted. Assessment Scales The National Institutes of Health Stroke Scale (NIHSS) was employed at baseline to evaluate stroke severity. The Modified Rankin Scale (mRS) was employed to assess clinical outcomes at baseline and during a three-month follow-up period. The mRS score varied from 0 (asymptomatic) to 6 (mortality). Classification of Stroke Stroke subtypes were categorised according to the TOAST (Trial of ORG 10172 in Acute Stroke Treatment) guidelines, utilising imaging results and relevant risk variables. Data Analysis All acquired data were subjected to statistical analysis employing suitable methodologies. The outcomes were presented as mean, standard deviation, and percentages. Relationships among variables were examined utilising appropriate statistical techniques (such as the Chi-square test, t-test, or correlation analysis) based on the data type. A p-value of less than 0.05 was deemed statistically significant.

Table 1: Age Group vs Sex

p-value = 0.49

The study included 50 participants, with a male predominance (64%) compared to females (36%). Most participants were in the 36–40 years age group (60%), followed by 31–35 years (36%), while only 4% were below 30 years. Males outnumbered females across all age groups, with the <30 category comprising only males. However, the association between age group and sex distribution was not statistically significant (p = 0.49).

Table 2: Sex

Table 2 presents the sex distribution of the study participants. Males constituted the majority (64%), while females accounted for 36%. This indicates a male predominance in the study sample.

Table 3: Gender with Final mRS Score

P-value = 0.003

Table 3 compares sex with final modified Rankin Scale (mRS) scores. Among females, most fell into categories of no significant disability (44.4%) and moderate disability (44.4%), with smaller proportions showing no symptoms, slight disability, or severe outcomes. In contrast, males were more frequently distributed across slight disability (28.1%) and moderate disability (15.6%), with fewer in severe disability. Notably, deaths occurred only among females (11.1%). The difference was statistically significant (p = 0.003), suggesting that sex was associated with differing functional outcomes after the clinical event.

Table 4: Age with Final mRS Score

P-value = 0.002

Among the 50 study participants, the majority were in the 36–40 years age group (60%), followed by 31–35 years (36%) and <30 years (4%). In the <30 years group, all participants had no significant disability. In the 31–35 years group, outcomes were heterogeneous, with distribution across all mRS categories including deaths (n = 2). In the 36–40 years group, a higher proportion of participants had moderate to severe disability (n = 15), with no deaths reported. Overall, increasing age group showed a trend toward worse functional outcomes, with higher proportions of moderate and severe disability in the older age groups. This association between age group and final mRS score was statistically significant (p = 0.002), indicating that age is an important determinant of functional outcome in the study population.

Table 5: Dyslipidemia with Final mRS Score

p-value = 0.10

Table 5 compares the presence of dyslipidemia with final modified Rankin Scale (mRS) outcomes. Among participants with dyslipidemia, most showed some level of disability—slight (28%) or moderate (32%)—and deaths were observed only in this group (8%). In contrast, those without dyslipidemia more often had no significant disability (40%), though moderate and severe disability were also present. The difference was not statistically significant (p = 0.10), suggesting that while dyslipidemia was linked to a trend of worse functional outcomes, the association was not strong enough to be conclusive.

Table 6: Smoking with Final mRS Score

P-value = 0.009

Table 6 analyzes the association between smoking and final modified Rankin Scale (mRS) outcomes. Among smokers, the majority fell into categories of no significant disability (33.3%) and slight disability (30%), with a notable proportion showing severe disability (20%). In contrast, non-smokers more often had either no symptoms (15%) or moderate disability (40%), with deaths occurring only among non-smokers (10%). The association was statistically significant (p = 0.009), suggesting that smoking status had a meaningful influence on functional outcomes, with smokers showing higher rates of disability but no recorded deaths.

Table 7: Alcohol with Final mRS Score

P-value = 0.04

Table 7 compares alcohol consumption with final modified Rankin Scale (mRS) outcomes. Among alcohol users, slight disability (38.1%) and no significant disability (28.6%) were most common, with a considerable proportion experiencing severe disability (19%). In non-users, outcomes were more varied, with moderate disability (34.5%) being the most frequent and deaths observed only in this group (6.9%). The association was statistically significant (p = 0.04), indicating that alcohol use was linked to distinct functional outcome patterns, with higher disability but no recorded deaths among users.

Table 8: Diabetes with Final mRS Score

P-value = 0.69

Table 8 examines the association between diabetes and final modified Rankin Scale (mRS) outcomes. Among diabetics, the most frequent outcomes were slight and moderate disability (30.8% each), with some experiencing severe disability (15.4%), but no cases of death or complete recovery without symptoms. In contrast, non-diabetics showed a wider distribution, including cases with no symptoms (8.1%) and deaths (5.4%). The difference was not statistically significant (p = 0.69), suggesting that diabetes did not have a strong impact on functional outcomes in this study population.

Table 9: Hypertension with Final mRS Score

P-value = 0.01

Table 9 analyzes the association between hypertension and final modified Rankin Scale (mRS) outcomes. Among hypertensive patients, slight (35%) and moderate disability (30%) were most common, with deaths observed in 10% of cases. In contrast, non-hypertensive patients more often had no significant disability (43.3%), while severe disability was seen equally in both groups. The association was statistically significant (p = 0.01), indicating that hypertension was linked to poorer functional outcomes and higher mortality risk.

Table 10: IHD with Final mRS Score

Table 10 examines the association between ischemic heart disease (IHD) and final modified Rankin Scale (mRS) outcomes. Among patients with IHD, outcomes were generally worse, with higher proportions experiencing moderate disability (25%), severe disability (25%), and death (25%), and none achieving complete recovery without symptoms. In contrast, non-IHD patients more often had favorable outcomes, including no symptoms (7.1%) or no significant disability (31%), with no deaths recorded. The difference was statistically significant (p = 0.03), indicating that IHD was strongly associated with poorer functional outcomes and higher mortality.

Table 11: Other Risk Factors with Final mRS Score

P-value = 0.59

Table 11 compares other risk factors with final modified Rankin Scale (mRS) outcomes. Among those with additional risk factors, the distribution was broad, with the largest proportion having no significant disability (31.3%), while severe disability and deaths were also observed (18.8% and 6.3%, respectively). In participants without other risk factors, moderate disability (38.9%) was most common, with no deaths reported. The association was not statistically significant (p = 0.59), indicating that the presence of other risk factors did not have a clear impact on functional outcomes.

Table 12: Clinical Variables with NIHSS Score

Table 12 presents the association between clinical variables and NIHSS stroke severity. Age showed no significant association, though most severe strokes occurred in the 31–40 age group. Sex was significantly associated (p = 0.04), with males more likely to present with minor and moderate strokes, while females more often had moderate-to-severe strokes. Alcohol use showed a borderline association (p = 0.05), with severe strokes occurring more frequently among alcoholics. Other variables, including dyslipidemia, smoking, diabetes, hypertension, IHD, and other risk factors, did not show statistically significant associations (p > 0.05), though trends suggested worse outcomes in hypertensives and those with multiple comorbidities. Overall, sex and alcohol consumption emerged as significant factors influencing stroke severity.

Table 13: Associated Symptoms — Number (Percentage)

Table 13 summarizes the associated symptoms observed in the study population. The most common symptom was speech abnormalities (48%), followed by drowsiness (24%) and numbness (18%). Less frequent symptoms included ataxia (14%), headache (8%), vomiting (6%), diplopia (4%), and loss of consciousness (4%). This indicates that neurological deficits, particularly speech disturbances, were the predominant associated clinical features.

Table 14: Clinical Signs with Final mRS Score

P-value = 0.82

Table 14 compares clinical signs with final modified Rankin Scale (mRS) outcomes. The majority of patients presented with weakness alone (72%), and their outcomes ranged across all disability levels, including deaths. Those with combined weakness and giddiness (12%) or giddiness alone (12%) had smaller distributions, while blurring was rare (4%). Although weakness was the predominant presenting sign, the differences in final outcomes across symptom groups were not statistically significant (p = 0.82), indicating that presenting clinical signs did not strongly influence long-term functional status.

Table 15: Speech with Final mRS Score

P-value < 0.001

Table 15 analyzes the association between speech abnormalities and final modified Rankin Scale (mRS) outcomes. Patients with speech impairment (54%) more frequently experienced moderate (37%), severe disability (29.6%), and deaths (7.4%), whereas those without speech abnormalities (46%) more often had no significant disability (43.5%) or slight disability (30.4%), with no severe outcomes or deaths. The difference was highly significant (p < 0.001), indicating that speech abnormalities were strongly associated with poorer functional outcomes.

Table 16: Clinical Variables with NIHSS Score

Table 16 examines the association between clinical variables and NIHSS stroke severity. Clinical signs showed a highly significant association (p < 0.001), with giddiness and weakness-related presentations distributed across minor and moderate strokes. Limb involvement also significantly influenced severity (p = 0.038), with patients having two-limb involvement (76%) more frequently progressing to moderate and moderate-to-severe strokes compared to those with single-limb or four-limb involvement. Speech abnormalities were strongly associated (p = 0.002), with affected patients more likely to present with moderate-to-severe strokes. Sensory involvement also showed significance (p = 0.021), with the majority experiencing moderate-to-severe strokes. In contrast, cerebellar signs had no significant impact (p = 0.928). Overall, speech, sensory, limb involvement, and clinical signs were key determinants of stroke severity on the NIHSS scale.

Table 17: Cranial Nerves Involved with Final mRS Score

Table 17 examines the relationship between cranial nerve involvement and final modified Rankin Scale (mRS) outcomes. The most common group was patients without cranial nerve signs (50%), showing a wide range of outcomes, including deaths. Among those with cranial nerve involvement, the VII nerve was most frequently affected (36%), associated largely with moderate to severe disability. Less frequent patterns, such as combinations of VII with VIII or XII, and isolated III, IV, VI involvement, were rare but still showed some degree of disability. The distribution suggests that cranial nerve involvement, particularly facial nerve (VII), tended to be associated with worse functional outcomes, although the overall variation indicates heterogeneity in prognosis.

Table 18: Etiology

Table 18 presents the distribution of stroke etiology in the study population. Atherosclerosis was the most common cause (34%), followed by unknown etiology in 28% of cases. Cardioembolic strokes and other identified causes each accounted for 16%, while lacunar infarcts were the least frequent (6%). This highlights that atherosclerosis was the leading cause, though a considerable proportion of cases remained of undetermined origin.

Table 19: Area of Involvement

Table 19 shows the distribution of vascular territories involved in the study population. The majority of cases (84%) were due to middle cerebral artery (MCA) involvement, followed by anterior cerebral artery (ACA) in 8%, combined MCA + PCA in 6%, and posterior cerebral artery (PCA) in only 2%. This indicates that MCA territory strokes were by far the most common in this cohort.

Table 20: Side of Involvement

Table 20 presents the side of brain involvement in stroke cases. Left-sided strokes were more common (68%) compared to right-sided strokes (32%), with no bilateral involvement reported. This indicates a predominance of left hemisphere strokes in the study population.

Table 21: Initial mRS with Final mRS Score

P-value < 0.001

Table 21 compares initial mRS with final mRS outcomes. Patients who initially had no significant disability largely maintained favorable outcomes, while those with slight or moderate disability showed mixed progress, with some improvement but also persistence of deficits. In contrast, patients with initial severe disability (48%) predominantly remained in the moderate-to-severe categories or progressed to death (8%). The association was highly significant (p < 0.001), indicating that baseline mRS strongly predicted final functional outcomes.

Table 22: NIHSS with Final mRS Score

P-value < 0.001

Table 22 examines the association between NIHSS stroke severity and final modified Rankin Scale (mRS) outcomes. Patients with minor strokes (34%) had the most favorable prognosis, with most achieving no symptoms (17.6%) or slight disability (41.2%), and none progressing to severe disability or death. Moderate strokes (42%) showed a broader distribution, including moderate (33.3%) and severe disability (28.6%). Those with moderate-to-severe strokes (16%) predominantly ended with moderate (75%) or severe disability (25%). Severe strokes (8%) were associated with the worst outcomes, including disability and death (50% each). The association was highly significant (p < 0.001), confirming that higher NIHSS scores strongly predicted poorer functional outcomes.

Epidemiology and Demographic Profile Ischaemic stroke is increasingly recognised among younger adults, particularly in low- and middle-income countries. Our study showed a predominance of males, more cases in the older part of the young-adult group, and a high prevalence of traditional vascular risk factors. Similar findings have been reported in young stroke populations, highlighting the need for early prevention. [2,13,14] Clinical Severity, Presentation and Functional Outcome Greater stroke severity at admission was strongly associated with poorer functional outcomes at discharge. Speech disturbances and involvement of multiple limbs were also linked to unfavourable outcomes. Although younger patients may recover better than older adults, age alone does not ensure a good prognosis; early treatment and prevention of complications remain essential. [15] Vascular Risk Factors Traditional risk factors such as hypertension, dyslipidaemia, smoking, alcohol use, and ischaemic heart disease were common among young stroke patients. Hypertension, smoking, and alcohol use were associated with greater disability, emphasising the importance of early screening, lifestyle modification, and risk-factor management. [16,17] Etiology, Classification and Undetermined Causes Stroke in young adults has diverse causes, including both traditional mechanisms and less common conditions such as arterial dissection and prothrombotic states. Our study found a considerable proportion of cases with undetermined aetiology, reflecting the limitations of diagnostic evaluation and classification systems such as TOAST. [18] Stroke Topography, Lateralisation and Their Implications In our cohort, the involvement of the middle cerebral artery (MCA) area and left hemispheric strokes was significant, and it was noted that left-hemisphere strokes, often associated with speech and language difficulties, corresponded with poorer functional outcomes. This discovery is consistent with extensive stroke literature: cortical large-artery infarcts, particularly in the dominant hemisphere, typically result in greater disability, earlier identification, and higher NIHSS scores compared to less severe lacunar or posterior circulation events. The data about younger individuals demonstrates a similar trend; for instance, when younger patients have dominant hemisphere deficiencies (aphasia, neglect), their prognosis tends to resemble that of older adults. Consequently, our findings align with the comprehension that in younger adults, the mere occurrence of a stroke is not innocuous; strokes affecting the dominant hemisphere or significant vascular territories pose a substantial risk of disability, and a younger age does not inherently ensure a mild presentation or recovery. Stroke teams treating younger persons must uphold the same urgency for imaging, reperfusion, and rehabilitation as they do for older adults. Prognosis, Functional Recovery and Public Health Implications Young adults with ischaemic stroke may have lower mortality but can experience significant long-term disability, requiring rehabilitation, secondary prevention, and regular follow-up. Hypertension, ischaemic heart disease, smoking, and alcohol use were associated with poorer outcomes, highlighting the importance of early risk-factor control. [44] The increasing burden of young-adult stroke in low- and middle-income countries, including India, emphasises the need for early screening, healthy lifestyle practices, public awareness, and improved stroke-care services. [2] Stroke during the economically productive years can have major social and financial consequences for patients and families. Gender differences in outcomes also suggest the need for equitable access to treatment and rehabilitation. The predominance of middle cerebral artery involvement, particularly left-sided strokes with speech deficits, may explain the significant neurological impairment observed. Early recognition, rapid referral, and access to reperfusion therapies such as thrombolysis and thrombectomy are essential for improving outcomes. Finally, the association of smoking and alcohol use with stroke severity and disability supports stronger public-health measures promoting smoking cessation, responsible alcohol use, and lifestyle modification. Metabolic Risk, Etiology and Healthcare Implications The interaction between hypertension and dyslipidaemia suggests that genetic, dietary, and sedentary lifestyle factors may contribute to early atherosclerosis and vascular ageing in Indian populations. The clustering of metabolic risk factors may increase the risk of stroke at younger ages. Although diabetes was not significantly associated with short-term functional outcomes, this may be related to sample size, short follow-up, or other confounding factors. Its effects may be more evident in long-term recurrence and vascular complications. Ischaemic heart disease was associated with poorer functional recovery, highlighting the shared vascular mechanisms between cardiac and cerebrovascular disease and the need for comprehensive cardiovascular assessment. The high proportion of strokes with undetermined aetiology reflects ongoing diagnostic challenges. Occult atrial fibrillation, patent foramen ovale, and hypercoagulable states should be considered through appropriate cardiac, vascular, and laboratory investigations. Delayed healthcare seeking may reduce access to timely thrombolysis or thrombectomy. Public awareness of FAST symptoms, rapid emergency transport, and improved referral systems are therefore essential. At the health-policy level, young-adult stroke should be included in NCD prevention programs, with early screening for blood pressure, cholesterol, and glucose, supported by health initiatives and regional stroke registries.

In conclusion, our findings highlight the evolving paradigm of ischaemic stroke in younger adults: the previously uncommon "young stroke" has become sufficiently prevalent to necessitate tailored attention, with a significant portion of the burden attributable to modifiable vascular risk factors once considered primarily relevant to older adults. The correlations identified between risk variables and adverse functional outcomes, the significance of dominant-hemisphere participation, and the considerable proportion of uncertain aetiology all reflect the worldwide literature. In our location and context, this indicates that younger individuals—particularly males aged 30 to 40 with hypertension, smoking habits, dyslipidaemia, or a history of ischaemic heart disease—should be seen as at heightened risk for stroke, rather than being considered “low risk due to youth.” Prevention, acute treatment, rigorous risk-factor management, and long-term follow-up are equally essential for younger persons as they are for older populations.

Conflict of Interest: None

Funding Support: Nil

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