Ischemic stroke in a healthy young adult: case report

The incidence of ischemic stroke (IS) in <35-year-old patient population ranges from 1,5-4,5 per 100’000. The cause of IS in young patients sometimes remains unknown as there is a lack of the traditional risk factors. We are presenting an uncommon case of a 28-year-old male IS patient. The patient had an unknown onset of confusion, left gaze palsy, marked left central facial nerve palsy, severe hemiparesis on the left side, tendon reflexes sin > dx, moderate superficial and deep sensation impairment on the left side. On admission Glasgow Coma Scale (GCS)- 14, NIH Stroke Scale (NIHSS)- 13, modified Rankin’s Scale (mRS)- 5. Brain computed tomography (CT) + CT angiogram was performed revealing proximal middle cerebral artery occlusion and malignant ischemia on the left hemisphere. Due to the unknown stroke onset and the CT finding acute revascularization treatment was contraindicated and patient was admitted to stroke unit for symptomatic treatment. On the next day patient deteriorated – GCS- 7, NIHSS- 22. A control CT showed severe brain edema and brain herniation. An urgent decompressive craniectomy was performed and patient was transferred to intensive care unit (ICU). After 11 days in ICU patient was transferred to Neurology department and post stroke rehabilitation was initiated. During this time in the hospital patient underwent an etiopathogenetic examination that included Holter monitoring, transthoracic and transesophageal echocardiogram, screening for systematic disease, thrombophilia and Fabry disease. No plausible cause for IS was identified. The diagnosis was defined using Trial of Org 10172 in Acute Stroke Treatment (TOAST) criteria as IS of undetermined etiology. A secondary prevention with rivaroxaban and acetylsalicylic acid was initiated. After 22 days from admission patient was discharged from the hospital to rehabilitation center. GCS-15, NIHSS-12, mRS-5. A follow-up by a neurologist and a neurosurgeon was planned in 3 months.