Neurological Sciences (2021) 42:639–645

https://doi.org/10.1007/s10072-020-04584-2

ORIGINAL ARTICLE

Ischemic stroke in young adults in Bogota, Colombia:

a cross-sectional study
Maria Paula Aguilera-Pena 1 & Andres Felipe Cardenas-Cruz 1 & Ivan Baracaldo 1,2 & Elkin Garcia-Cifuentes 1,3 &
Maria Isabel Ocampo-Navia 1 & Elza Juliana Coral 1,2

Received: 14 December 2019 / Accepted: 5 July 2020 / Published online: 10 July 2020
# Fondazione Società Italiana di Neurologia 2020

Abstract
Background There has been an increase in the incidence of ischemic stroke in young adults. It is believed that it is due to the
increase in traditional cardiovascular risk factors. This change has affected the quality of life of young adults.
Aims To describe the most common etiologies and risk factors in patients aged ≤ 50 who had ischemic stroke between 2011 and 2018.
Methodology A cross-sectional study of patients under 50 years who had ischemic stroke between 2011 and 2018 who were
evaluated at a comprehensive center in Bogotá, Colombia. We carried out a descriptive analysis of comorbidities, the Trial of Org
for Acute Stroke (TOAST), the National Institute of Health Stroke Scale (NIHSS), and the modified Rankin Scale (mRS).
Results A total of 152 patients were included, out of which 50.66% were men. The most frequent traditional risk factors were
smoking history (19%), history of high blood pressure (18%), presence of cardiovascular disease (17%), and history of migraine
(15%). The most common etiological subgroups were those classified as “other determined etiologies” (33.5%) and “undeter-
mined etiology” (33.5%), while the most common etiology was carotid or vertebral artery dissection (23%).
Conclusion This study demonstrates the need to make a deep evaluation of the past medical history, laboratory tests, and new risk
factors in young adults. On the other hand, modifiable cardiovascular risk factors top the list, showing the need to implement
health promotion strategies for young adults.

Keywords Ischemic stroke . Young adults . Risk factors . Etiology

Introduction prevalence of traditional cardiovascular risk factors [1, 2].

Ischemic stroke is a disease commonly seen in older adults;
since 1980, the incidence of ischemic stroke in young adults
has been increasing; as a consequence of this, the quality of
life of younger adults has been affected. The most accepted
theories explaining this include improved neuroimaging
methods, increased use of illicit drugs, and a higher
Electronic supplementary material The online version of this article
(https://doi.org/10.1007/s10072-020-04584-2) contains supplementary
material, which is available to authorized users.
* Maria Paula Aguilera-Pena
mariapaulaaguilerap@gmail.com
1
Pontificia Universidad Javeriana, Bogotá, Colombia
2
Hospital Universitario San Ignacio, Bogotá, Colombia
3
Instituto de Envejecimiento, Pontificia Universidad Javeriana,
Bogotá, Colombia
The incidence of ischemic stroke in adults under 45 years
varies between 11.3 and 22.8 per 100,000 people/year [3, 4].
The age to define ischemic stroke in young adults varies
across the literature. However, most studies define it between
18 and 49 years of age [1, 5]; for this reason, our study is
governed by the same parameters.
Long-term follow-up studies in young adults show that the
cumulative 5-year mortality ranges between 9 and 11% [6, 7].
Mortality risk is higher the first year after the event, especially
the first month. There are several predictors for mortality in
young adults with ischemic stroke, which are as follows: ma-
lignancy, > 45 years, heavy drinking, diabetes mellitus type 1,
heart failure, infection in the month prior, large artery athero-
sclerosis stroke, and cardioembolic stroke [8].
It is reported that the proportion of individuals with a result
greater than 2 when using the mRS varies between 6 and 20% in
a 3- to 12-year follow-up and only 40% of young adults returned
to work after suffering an ischemic stroke [9, 10]. One of the
main factors that affect work in young adults is motor
640
impairment; most of patients with moderate/severe limb paresis
or aphasia did not return to work within the first year [11].
Ischemic stroke risk factors in young people differ world-
wide and depend on factors such as genetic differences, sex,
environmental factors, and accessibility to health services [12,
13]. Studies conducted to characterize the young population
with ischemic stroke have shown different proportions with
respect to the etiological characterization, so it is imperative to
conduct studies that represent populations with diverse ethnic
and geographical background [10, 12, 14]. There is only one
Colombian study published in 2001 analyzing 14 patients
with stroke, describing the etiology and risk factors [15].
Aims
To describe the etiology and risk factors in patients under
50 years who suffered from ischemic stroke between 2011
and 2018 in a referral center in Bogotá, Colombia. The sec-
ondary objective was to describe the frequency of each etiol-
ogy and the risk factors according to sex and age group.
Methods
We conducted a descriptive cross-sectional study at Hospital
Universitario San Ignacio in Bogotá, using a non-probability
convenience sampling from medical records of all patients
aged 18 to 49 years with a diagnosis of ischemic stroke be-
tween January 2011 and May 2018. We excluded patients
with ischemic stroke secondary to cardiovascular surgery, in-
tracranial surgery, coronary or aortic cervical angiography,
direct cervical trauma, or carotid endarterectomy. The ethics
committee from Hospital Universitario San Ignacio in Bogotá
approved the study; informed consent was not needed since
there was no direct contact with the patient.
The patients were initially examined by an emergency doc-
tor and later by a neurologist. One hundred percent of the
patients underwent complete blood count and basic metabolic
panel, electrocardiogram, non-contrast computed tomogra-
phy, and magnetic resonance imaging of the brain in patients
with suspected lacunar stroke. All brain imaging studies were
evaluated by a neuroradiologist. In addition, 100% of the pa-
tients underwent transesophageal echocardiography and vas-
cular images of extracranial vessels.
Patients who had all of the studies above negative underwent
studies for antiphospholipid syndrome (anticardiolipin antibod-
ies, antibeta2-glycoprotein antibodies, and lupus anticoagu-
lant), and hypercoagulability studies (Leiden factor V, protein
c/s, and antithrombin III) were also performed.
Data on diagnostic work-up and comorbidities
(Supplemental Table 1) were collected using a predefined pro-
tocol. The risk factors were selected according to the existing
Neurol Sci (2021) 42:639–645
evidence [1, 5–7]. We used the TOAST [16] as etiopathogenic
classification. The location of the infarct was evaluated accord-
ing to the vascular territories. To quantify objectively the dam-
age caused by the ischemic stroke, we used the NIHSS [17] for
which we used the cutoff points used in most of the studies for
categorization: mild (0–4 points), moderate (5–9 points), and
severe (> 10 points) [18]. Cardiovascular disease was defined
according to the definition of the American Society of
Cardiology: cerebrovascular disease, coronary heart disease,
and peripheral arterial disease [19].
For the analysis, we stratified patients by sex and age
groups as follows: (1) ≤ 44 years old and (2) ≥ to 45 years
old. We divided the study population for further compar-
isons into 2 cohorts, at age 44, because around this age,
the trends in classical cardiovascular risk factors were
clearly separated. To evaluate distribution, the Shapiro-
Wilk test was used. For parametric and non-parametric
distribution, central tendency measures for categorical
(counts and percentage) and continuous (median and in-
terquartile range) groups were used. For differences in
categorical groups, χ2 tests and Fisher’s exact test were
used, and for continuous groups, the Mann-Whitney U
test. We set the level of statistical significance at
p < 0.05. The RStudio® 1.2.1335 software was used for
the analysis.
Results
We identified 155 patients, 152 of which met the inclusion
criteria. Within the sample, 50.6% were men; the median age
was 41.
Of the total number of patients, 82.8% had at least one
cardiovascular risk factor. The most common risk factors were
smoking, arterial hypertension, and cardiovascular disease
(Table 1). Most of the classic cardiovascular risk factors were
more common in men than in women; however, the only one
that reached statistical significance was dyslipidemia. Of the
total number of patients, 80.2% had at least one non-classic
risk factor. The most frequent were migraine and chronic al-
cohol consumption. In the analysis of groups by age, mi-
graine, positive anticardiolipin antibodies, and cancer had sta-
tistically significant differences.
Table 2 shows the etiology of ischemic stroke. The 33.5%
were due to other determined etiologies and the 23.6% due to
cardioembolic events, while only 6.5% and 2.6% were due to
large artery atherosclerosis and small vessel disease, respec-
tively. The most frequent vascular territory was anterior. On
the other hand, more than half of the patients were classified as
mild infarcts. In the mRS, 97.3% of the patients had no sig-
nificant previous disability.
The most common cause of cardioembolic ischemic stroke
was patent foramen oval (Table 3). Within the category of
Neurol Sci (2021) 42:639–645 641

Table 1 Demographic data and risk factors by sex and age groups

All (n = 152) Women (n = 75) Men (n = 77) p ≤ 44 years (n = 102) ≥ 45 years (n = 50) p

Non-modifiable risk factors

Age 41 (36–46)* 41 (33–45) 43 (33-46) 0.6 37 (30–41) 47 (46–48)
Gender 75 (49.34) 77 (50.65) 53/49** 22/28** 0.4
Family history 2 (1.3) 2 (2.6) 0 (0) 0.2 1 (0.9) 1 (2) 0.5
Classic risk factors
Smoking 29 (19.1) 10 (13.3) 19 (24.6) 0.1 18 (17.6) 11 (22) 0.6
High blood pressure 28 (18.4) 13 (17.3) 15 (19.4) 0.8 14 (13.7) 14 (28) 0.05
Cardiovascular disease 27 (17.7) 14 (18.6) 13 (16.8) 0.9 12 (11.7) 15 (30) 0.01
Previous stroke 13 (8.5) 6 (8) 7 (9.1) 1 7 (6.8) 6 (12) 0.3
Heart failure 6 (3.9) 3 (4) 3 (3.9) 1 2 (1.9) 4 (8) 0.09
Acute myocardial infarction 4 (2.6) 2 (2.6) 2 (2.6) 1 1 (0.9) 3 (6) 0.1
TIA 3 (1.9) 2 (2.6) 1 (1.3) 0.6 2 (1.9) 1 (2) 1
Peripheral arterial disease 1 (0.6) 1 (1.3) 0 (0) 0.4 0 (0) 1 (2) 0.3
Dyslipidemia 15 (9.8) 2 (2.6) 13 (16.8) 0.01 7 (6.8) 8 (16) 0.08
Diabetes mellitus 11 (7.2) 4 (5.3) 7 (9.1) 0.5 3 (2.9) 8 (16) 0.006
Obesity 8 (5.2) 6 (8) 2 (2.6) 0.1 3 (2.9) 5 (10) 0.1
Atrial fibrillation 5 (3.2) 3 (4) 2 (2.6) 0.6 3 (2.9) 2 (4) 0.6
Valvular atrial fibrillation 3 (1.9) 3 (4) 0 (0) 0.1 2 (1.9) 1 (2) 1
Other risk factors
Migraine 23 (15.1) 15 (20) 8 (10.3) 0.1 23 (22.5) 0 (0) 0.0006
Alcohol 20 (13.1) 7 (9.3) 13 (16.8) 0.2 16 (15.6) 4 (8) 0.2
Rheumatic disease 14 (9.2) 8 (10.6) 6 (7.7) 0.7 7 (6.8) 7 (14) 0.2
Valve replacement 14 (9.2) 5 (6.6) 9 (11.6) 0.4 8 (7.8) 6 (12) 0.3
PFO 9 (5.9) 5 (6.6) 4 (5.1) 0.7 7 (6.8) 2 (4) 0.7
APS 7 (4.6) 5 (6.6) 2 (2.6) 0.2 3 (2.9) 4 (8) 0.2
Lupus anticoagulant 6 (3.9) 4 (5.3) 2 (2.6) 0.4 4 (3.9) 2 (4) 1
Recent alcohol use 6 (3.9) 0 (0) 6 (7.7) 0.02 4 (3.9) 2 (4) 1
Anticardiolipin 5 (3.2) 4 (5.3) 1 (1.3) 0.2 1 (0.9) 4 (8) 0.04
Drugs 4 (2.6) 1 (1.3) 3 (3.9) 0.6 4 (3.9) 0 (0) 0.3
STD 3 (1.9) 0 (0) 3 (3.9) 0.2 2 (1.9) 1 (2) 1
Cancer 3 (1.9) 3 (4) 0 (0) 0.1 0 (0) 3 (6) 0.034
Sleep apnea 2 (1.3) 2 (2.6) 0 (0) 0.2 1 (0.9) 1 (2) 0.5
OCPs 2 (1.3) 2 (2.6) 0 (0) 0.2 2 (1.9) 0 (0) 1
Recent infection 2 (1.3) 1 (1.3) 1 (1.3) 1 1 (0.9) 1 (2) 0.5
Pregnancy 1 (0.6) 1 (1.3) 0 (0) 0.4 1 (0.9) 0 (0) 1
Collagen 1 (0.6) 0 (0) 1 (1.3) 1 0 (0) 1 (2) 0.3

*Interquartile ranges
**Woman/man
PFO patent foramen ovale, APS antiphospholipid syndrome, STD sexually transmitted disease, OCPs oral contraceptives

other determined etiologies, the most common was spontane-
ous carotid or vertebral artery dissection. In approximately
one third of the cases, the etiology of the ischemic event was
not clearly established.
When comparing the distribution of ischemic stroke
risk factors and etiological subtypes, we found a statisti-
cally significant difference in the history of diabetes
mellitus in the large vessel atherosclerosis group, as well
as smoking, cardiovascular disease, alcohol consumption,
and valve replacement in the cardioembolic stroke group.
In the lacunar stroke, only alcohol consumption reached
statistical significance, and in the group of other deter-
mined etiology, only arterial hypertension reached statis-
tical significance (Table 4).
642 Neurol Sci (2021) 42:639–645

Table 2 TOAST and location of the infarct by sex and age groups

All (n = 152) Women (n = 75) Men (n = 77) p ≤ 44 years (n = 102) ≥ 45 years (n = 50) p

Etiology by TOAST classification

1. Large artery atherosclerosis 10 (6.5) 2 (2.6) 8 (10.3) 0.09 4 (3.9) 6 (12) 0.08
2. Cardioembolic 36 (23.6) 21 (28) 15 (19.4) 0.2 22 (21.5) 14 (28) 0.5
3. Small-vessel occlusion (lacunar) 4 (2.6) 1 (1.3) 3 (3.9) 0.6 2 (1.9) 2 (4) 0.5
4. Other determined etiology 51 (33.5) 21 (28) 30 (38.9) 0.2 38 (37.2) 13 (26) 0.2
5a. Multiple potential etiologies 7 (4.6) 6 (8) 1 (1.3) 0.06 6 (5.8) 1 (2) 0.4
5b. Negative evaluation 7 (4.6) 5 (6.6) 2 (2.6) 0.2 5 (4.9) 2 (4) 1
5c. Incomplete evaluation 37 (24.3) 19 (25.3) 18 (23.3) 0.9 25 (24.5) 12 (24) 1
Location of infarct by vascular territory
Anterior territory 79 (51.9) 42 (56) 37 (48.1) 0.4 48 (47.1) 31 (62) 0.1
Thalamus 6 (3.9) 3 (4) 3 (3.9) 1 3 (2.9) 3 (6) 0.3
Posterior territory 47 (30.9) 21 (28) 26 (33.7) 0.5 36 (35.2) 11 (22) 0.1
Multiterritorial 20 (13.1) 9 (12) 11 (14.2) 0.8 15 (14.7) 5 (10) 0.5
NIHSS
Mild (0–4) 88 (57.8) 39 (52) 49 (63.6) 0.1 67 (65.6) 21 (42) 0.009
Moderate (5–9) 34 (22.3) 19 (25.3) 15 (19.4) 0.5 18 (17.6) 16 (32) 0.07
Severe (> 10) 30 (19.7) 17 (22.6) 13 (16.8) 0.4 17 (16.6) 13 (26) 0.2
mRS
Asymptomatic 134 (88.1) 67 (89.3) 67 (87) 0.8 92 (90.2) 42 (84) 0.3
No significant disability 14 (9.2) 6 (8) 8 (10.3) 0.8 7 (6.8) 7 (14) 0.2
Mild disability 2 (1.3) 1 (1.3) 1 (1.3) 1 1 (0.9) 1 (2) 0.5
Moderate disability 0 (0) 0 (0) 0 (0) 0 (0) 0 (0)
Moderately severe disability 1 (0.6) 0 (0) 1 (1.3) 1 1 (0.9) 0 (0) 1
Severe disability 1 (0.6) 1 (1.3) 0 (0) 0.4 1 (0.9) 0 (0) 1
Death 0 (0) 0 (0) 0 (0) 0 (0) 0 (0)

Discussion prevention strategies to avoid the incidence or recurrence of

ischemic strokes.
This is the first study done in Colombia regarding ischemic The reported incidence of ischemic stroke in young people
stroke in young adults, which demonstrates a high frequency has varied from 3 to 23 per 100,000 in the last 3 decades [20].
of modifiable risk factors in the young adult population; these There is no exact information about young stroke for
results showed the need to implement primary and secondary Colombia; however, the Territorial Information System on
Cerebrovascular Attack reported that between 2011 and
2015, there were 77,402 cases, out of which 14,858 occurred
in people under 50 years [12, 21]. In addition, young adults
Table 3 Most common etiologies have a longer average hospital stay and higher accumulated
costs compared with older patients [22].
Women Men Total Our study showed that, according to the TOAST classi-
fication, the most common etiologies corresponded to the
Cervical or vertebral artery dissection 13 (17.3) 23 (29.8) 36 (23.6)
categories of “undetermined etiology” and “other deter-
Permeable oval foramen 9 (12) 4 (5.1) 13 (8.5)
mined etiologies,” in which more than 10 different etiolo-
Septal aneurysm 4 (5.3) 5 (6.4) 9 (5.9)
gies were identified, confirming the great heterogeneity in
Acquired hypercoagulability 7 (9.3) 1 (1.3) 8 (5.2)
the etiology of ischemic stroke in young people.
Valve replacement 2 (2.6) 3 (3.9) 5 (3.2)
Spontaneous cerebral and cervical artery dissection was
APS 3 (4) 2 (2.6) 5 (3.2)
the most common etiology, with an overall frequency of
Atrial fibrillation 3 (4) 2 (2.6) 5 (3.2)
23.6%, followed by patent oval foramen, septal aneurysm,
Migraine 2 (2.6) 0 (0) 2 (1.32)
and hypercoagulability, which is similar to information
APS antiphospholipid syndrome from large cohorts [1, 3, 5, 14, 23].
Neurol Sci (2021) 42:639–645 643

Table 4 TOAST and main risk factors

Large artery Cardioembolic Lacunar Other Multiple Negative Incomplete

atherosclerosis determined potential evaluation evaluation
etiology etiologies

Classic risk factors

Smoking 4 (40) 2 (5.5)* 2 (50) 9 (17.6) 0 (0) 1 (14.2) 11 (29.7)
High blood pressure 4 (40) 9 (25) 1 (25) 3 (5.8)* 1 (14.2) 3 (42.8) 7 (18.9)
Cardiovascular 3 (30) 12 (33.3)* 0 (0) 8 (15.6) 0 (0) 0 (0) 4 (10.8)
disease
Dyslipidemia 2 (20) 3 (8.3) 1 (25) 3 (5.8) 0 (0) 1 (14.2) 5 (13.5)
Diabetes mellitus 4 (20)* 3 (8.3) 1 (25) 1 (1.9) 0 (0) 0 (0) 2 (5.4)
Other risk factors
Migraine 1 (10) 5 (13.8) 0 (0) 8 (15.6) 2 (28.5) 1 (14.2) 6 (16.2)
Alcohol use 2 (20) 1 (2.7)* 3 (75)* 5 (9.8) 0 (0) 1 (14.2) 8 (21.6)
Rheumatic disease 0 (0) 5 (13.8) 0 (0) 5 (9.8) 1 (14.2) 1 (14.2) 2 (5.4)
Valve replacement 0 (0) 8 (22.2)* 0 (0) 2 (3.9) 0 (0) 0 (0) 4 (10.8)

*p = < 0.05

A recent review of ischemic stroke in young adults showed
that in South and Central America, the infectious diseases are
an important etiology of ischemic stroke in young adults; nev-
ertheless, in our study, that is not the case. The explanation is
that even though Colombia is a developing country, Bogota is
a city with excellent healthcare services and low prevalence of
infectious disease compared with the rest of the cities. There is
a need to characterize the whole country including the people
in rural areas in order to know if infectious diseases are an
important cause of ischemic stroke in young adults [13].
In the “undetermined etiology” category, 24.3% of patients
were classified as “insufficient evaluation.” These results can
be explained by an inadequate recognition of predisposing
genetic factors, poorly understood risk factor interactions, or
difficulty in the patient’s follow-up [10].
Recent studies report rates of cryptogenic ischemic stroke
range from 24 to 36% [24, 25], like those of our series.
However, it has been documented that the frequency of cryp-
togenic ischemic strokes varies according to the diagnostic
criteria and the classification system used for each etiological
subtype; besides, it should be noted that the potential risk
factors for a cryptogenic ischemic stroke in young people
and the association with classic cardiovascular risk factors
have not been systematically studied [1, 26].
This study showed that smoking was one of the main risk
factors in the category of “undetermined etiology”; however,
the exact pathophysiological mechanism between smoking
and cryptogenic ischemic stroke is unknown, since only a
few studies have specifically evaluated the association be-
tween traditional cardiovascular risk factors and cryptogenic
stroke [26]. What is known is that smoking increases the risk
of ischemic stroke in young adults, as demonstrated in a case-
control study conducted in the USA that determined that there
is a strong dose-response relationship between smoking and
ischemic stroke (OR of 2.2 when comparing current smokers
with non-smokers) [27].
Although there was a high incidence of classic and modi-
fiable cardiovascular risk factors in the study, the proportion
of large vessel atherosclerosis and small vessel disease was
very low; in fact, it was lower than generally reported [1, 3].
These results suggest that cardiovascular risk factors increase
the risk of suffering ischemic events from other pathophysio-
logical mechanisms that have not yet been clearly documented
and should be studied [14].
Our study found a very low percentage of patients with a
family history of cerebrovascular disease (1.32%). This differs
from the findings of an observational study, which showed a
frequency of 63% [21]. This may be due to the complexity of
the ischemic stroke heritability mechanisms [24]. In addition,
it has been shown that the etiology in the young population
varies by geographic region and has a greater heterogeneity
compared with that in the older adult population [14].
Likewise, the prevalence of ischemic stroke in the young pop-
ulation of South America is lower compared with that in the
population of developed countries, which supports the hy-
pothesis set out above [28].
Dyslipidemia was more common in men than in women,
like the findings of several of the studies reviewed [14]. This
can be explained by the reproductive characteristics of most
women under 50. Several studies have shown that lipid regu-
lation is impaired by menopause, especially due to the de-
crease in endogenous estrogens; in addition, young women
have a better lipid metabolism compared with men and men-
opausal women. This leads to a lower ischemic stroke fre-
quency in women compared with men within this age group
[29, 30]. In our study, there were more men than women;
644
however, the difference in the averages was 1.32%, without
statistical significance.
The frequency of migrainous stroke found in our study was
like the studies reviewed [21, 24]. Women had a higher fre-
quency of migraine compared with men [31]. We identified 4
patients with a history of migraine and concomitant smoking,
2 of which were women. These results are consistent with the
literature, as the most important risk factors for migrainous
stroke are migraine with aura, female gender, tobacco use,
and exogenous estrogens [32–34].
The limitations of our study were as follows: (1) Sampling
was performed by convenience which resulted in the impos-
sibility to make general statements with statistical rigor on the
population. (2) In some of statistical analyses, the expected
values were small; this may lead to the p value not being
accurate. (3) Almost one quarter of patients were classified
in the category of “insufficient evaluation”; this can be ex-
plained because the studies for antiphospholipid syndrome
and hypercoagulability had to be repeated at 6 weeks to in-
crease sensitivity and specificity, and most of these were per-
formed outside our institution, making it impossible to follow
up on patients; and (4) the TOAST scale was used to evaluate
the patients. However, in the literature, there are several clas-
sification systems for ischemic stroke in young patients such
as ASCOD [35], and other that combines the TOAST and
Baltimore systems; these scales seek to prevent most patients
from being classified as “undetermined etiology” [21].
The most frequent etiological categories of the TOAST
classification were those corresponding to “another deter-
mined etiology” and “undetermined etiology.” This shows
the need to make a deep evaluation in terms of the past med-
ical history, laboratory tests, and new risk factors. On the other
hand, it has been shown that patients under 45 years have
fewer classic cardiovascular risk factors, so the definition
could be changed to all those under 45 years; however, it is
necessary to standardize this worldwide [36].
Contrary to what is commonly believed, this study showed
no etiologies of very low prevalence. A higher frequency of
modifiable cardiovascular risk factors was found, such as high
blood pressure, a history of cardiovascular disease, smoking,
dyslipidemia, and chronic alcohol consumption, which shows
the need to implement prevention strategies to protect the
health of young adults. Finally, there is a great heterogeneity
in the data of the literature on ischemic stroke in young people,
depending on the geographical location. This highlights the
need for more research in each country.
Author contributions All authors contributed to the study conception,
design, material preparation, and data collection. Analyses were per-
formed by Maria Paula Aguilera Peña, Andrés Felipe Cardenas Cruz,
and Elkin Garcia Cifuentes. The first draft of the manuscript was written
by Maria Paula Aguilera Peña and Andrés Felipe Cardenas Cruz, and all
authors commented on previous versions of the manuscript. All authors
read and approved the final manuscript.
Neurol Sci (2021) 42:639–645
Compliance with ethical standards
Conflict of interest The authors declare that they have no conflict of
interest.
Ethical approval The ethics committee from Hospital Universitario San
Ignacio in Bogotá, Colombia approved the study.
References
1. Ekker MS, Boot EM, Singhal AB, Tan KS, Debette S, Tuladhar
AM, de Leeuw FE (2018) Epidemiology, aetiology, and manage-
ment of ischaemic stroke in young adults. Lancet Neurol 17:790–
801
2. Uggetti C (2003) Stroke in young people: imaging. Neurol Sci
24(S1):s15–s16
3. Kristensen B, Malm J, Carlberg B, Stegmayr B, Backman C,
Fagerlund M, Olsson T (1997) Epidemiology and etiology of is-
chemic stroke in young adults aged 18 to 44 years in Northern
Sweden. Stroke 28:1702–1709
4. Kittner SJ, McCarter RJ, Sherwin RW et al (1993) Black-White
differences in stroke risk among young adults. Stroke 24:15
5. Putaala J, Metso AJ, Metso TM, Konkola N, Kraemer Y,
Haapaniemi E, Kaste M, Tatlisumak T (2009) Analysis of 1008
consecutive patients aged 15 to 49 with first-ever ischemic stroke:
the Helsinki young stroke registry. Stroke 40:1195–1203
6. Fonarow GC, Reeves MJ, Zhao X, Olson DM, Smith EE, Saver JL,
Schwamm LH, Get With the Guidelines-Stroke Steering
Committee and Investigators (2010) Age-related differences in
characteristics, performance measures, treatment trends, and out-
comes in patients with ischemic stroke. Circulation 121:879–891
7. Kappelle LJ, Adams HP, Heffner ML, Torner JC, Gomez F, Biller J
(1994) Prognosis of young adults with ischemic stroke. A long-
term follow-up study assessing recurrent vascular events and func-
tional outcome in the Iowa Registry of Stroke in Young Adults.
Stroke 25(7):1360–1365
8. Putaala J, Curtze S, Hiltunen S, Tolppanen H, Kaste M, Tatlisumak
T (2009) Causes of death and predictors of 5-year mortality in
young adults after first-ever ischemic stroke: The Helsinki Young
Stroke Registry. Stroke 40(8):2698–2703
9. Varona JF, Bermejo F, Guerra JM, Molina JA (2004) Long-term
prognosis of ischemic stroke in young adults. Study of 272 cases. J
Neurol 251:1507–1514
10. Waje-Andreassen U, Thomassen L, Jusufovic M, Power KN, Eide
GE, Vedeler CA, Naess H (2013) Ischaemic stroke at a young age is
a serious event–final results of a population-based long-term
follow-up in Western Norway. Eur J Neurol 20:818–823
11. Aarnio K, Rodríguez-Pardo J, Siegerink B, Hardt J, Broman J,
Tulkki L et al (2018) Return to work after ischemic stroke in young
adults: a registry-based follow-up study. Neurology 91(20):e1909–
e1917
12. Maaijwee NAMM, Rutten-Jacobs LC, Schaapsmeerders P et al
(2014) Ischaemic stroke in young adults: risk factors and long-
term consequences. Nat Rev Neurol 10:315–325
13. Boot E, Ekker MS, Putaala J, Kittner S, De Leeuw F, Tuladhar AM
(2020) Ischaemic stroke in young adults: a global perspective. J
Neurol Neurosurg Psychiatry 91(4):411–417
14. Ji R, Schwamm LH, Pervez MA, Singhal AB (2013) Ischemic
stroke and transient ischemic attack in young adults: risk factors,
diagnostic yield, neuroimaging, and thrombolysis. JAMA Neurol
70:51–57
Neurol Sci (2021) 42:639–645
15. Saavedra M, Asociada P, Trujillo FG et al (2001) Factores de riesgo
en enfermedad cerebro vascular isquémica en pacientes menores de
45 años. Rev la Fac Med 49(2):89–99
16. Adams H Jr, Bendixen BH, Kappelle LJ, Biller J, Love BB, Gordon
DL et al (1993) Classification of subtype of acute ischemic stroke.
Definitions for use in a multicenter clinical trial. TOAST. Trial of
Org 10172 in Acute Stroke Treatment. Stroke 24(1):35. (d)
17. Lyden P, Brott T, Tilley B, Welch KM, Mascha EJ, Levine S et al
(1994) Improved reliability of the NIH Stroke Scale using video
training. NINDS TPA Stroke Study Group. Stroke 25(11):2220
18. Oliveira Filho MD, T Mullen MD. Initial assessment and manage-
ment of acute stroke. Post TW, ed. UpToDate. Waltham, MA:
UpToDate Inc https://www.uptodate.com (Accessed on June 02,
2019)
19. WF Wilson MD. Overview of established risk factors for cardio-
vascular disease. Post TW, ed. UpToDate. Waltham, MA:
UpToDate Inc. https://www.uptodate.com(Accessed on June 17,
2019)
20. Harmsen P, Berglund G, Larsson O, Tibblin G, Wilhelmsen L
(1979) Stroke Registration in Göteborg, Sweden, 1970–75. Acta
Med Scand 206:337–344
21. Rasura M, Spalloni A, Ferrari M, Castro S, Patella R, Lisi F, Beccia
M (2006) A case series of young stroke in Rome. Eur J Neurol 13:
146–152
22. Ellis C (2010) Stroke in young adults. Disabil Health J 3:222–224
23. Patella R, Spalloni A, Ferrari M, La Starza S, Bozzao A, Rasura M
(2011) Cerebral ischemia in young patients (under 45 years of age):
clinical and neuroradiological follow-up. Neurol Sci 32(3):427–432
24. Nedeltchev K, der Maur TA, Georgiadis D, Arnold M, Caso V,
Mattle HP, Schroth G, Remonda L, Sturzenegger M, Fischer U,
Baumgartner RW (2005) Ischaemic stroke in young adults: predic-
tors of outcome and recurrence. J Neurol Neurosurg Psychiatry 76:
191–195
25. Lee T-H, Hsu W-C, Chen C-J, Chen ST (2002) Etiologic study of
young ischemic stroke in Taiwan. Stroke 33:1950–1955
645
26. Jaffre A, Ruidavets JB, Nasr N, Guidolin B, Ferrieres J, Larrue V
(2015) Tobacco use and cryptogenic stroke in young adults. J
Stroke Cerebrovasc Dis 24:2694–2700
27. Bhat VM, Cole JW, Sorkin JD, Wozniak MA, Malarcher AM,
Giles WH, Stern BJ, Kittner SJ (2008) Dose-response relationship
between cigarette smoking and risk of ischemic stroke in young
women. Stroke 39:2439–2443
28. Saposnik G, Del Brutto OH (2003) Stroke in South America: a
systematic review of incidence, prevalence, and stroke subtypes.
Stroke 34:2103–2107
29. Koellhoffer EC, McCullough LD (2013) The effects of estrogen in
ischemic stroke. Transl Stroke Res 4:390–401
30. Cífková R, Krajčoviechová A (2015) Dyslipidemia and cardiovas-
cular disease in women. Curr Cardiol Rep 17:1–10
31. Camerlingo M, Romorini A, Ferrante C, Valente L, Moschini L
(2010 Jun) Migraine and cerebral infarction in young people.
Neurol Sci 31(3):293–297
32. Scher AI, Launer LJ (2010) Migraine with aura increases the risk of
stroke. Nat Rev Neurol 6:128–129
33. Laurell K, Artto V, Bendtsen L, Hagen K, Kallela M, Meyer EL,
Putaala J, Tronvik E, Zwart JA, Linde M (2011 Oct) Migrainous
infarction: a Nordic multicenter study. Eur J Neurol 18(10):1220–
1226
34. Altamura C, Cascio Rizzo A, Maggio P, Viticchi G, Paolucci M,
Brunelli N et al (2019) Prevalence and clinical profile of migraine
with aura in a cohort of young patients with stroke: a preliminary
retrospective analysis. Neurol Sci 40(S1):185–186
35. Amarenco P, Bogousslavsky J, Caplan LR, Donnan GA, Wolf ME,
Hennerici MG (2013) The ASCOD phenotyping of ischemic stroke
(Updated ASCO Phenotyping). Cerebrovasc Dis 36:1–5
36. Leys D, Bandu L, Hénon H et al (2002) Clinical outcome in 287
consecutive young adults (15 to 45 years) with ischemic stroke.
Neurology 59:26–33
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