CLINICAL CHARACTERISTICS, ETIOLOGIES, AND 1-YEAR OUTCOMES OF YOUNG ADULTS (<45 YEARS) WITH ISCHEMIC STROKE: A PROSPECTIVE COHORT STUDY FROM PAKISTAN

Abstract

Introduction
Ischemic stroke in young adults is increasingly recognized as a major public health concern, particularly in low- and middle-income countries where early-onset vascular risk factors are becoming more prevalent. Despite representing a clinically distinct population with unique etiologic patterns and long-term consequences, data from South Asia remain limited. Pakistan, with its large proportion of young adults and rising burden of hypertension, dyslipidemia, diabetes, and tobacco use, provides an important yet under-studied setting. This prospective cohort study aimed to characterize the clinical features, etiologic spectrum, and one-year outcomes of young adults (18–44 years) presenting with acute ischemic stroke to a major tertiary care center in northern Pakistan.

Methods
A prospective cohort study was conducted at Ayub Teaching Hospital, Abbottabad, enrolling consecutive patients aged 18–44 years with neuroimaging-confirmed ischemic stroke from July 2023 to July 2024. Participants were followed for 12 months, with the final follow-up completed in July 2025. Baseline demographics, vascular risk factors, clinical presentation, and stroke severity (NIHSS) were recorded using standardized forms. Etiologic classification was performed using TOAST criteria, with additional categories for arterial dissection, thrombophilia, and vasculitis. All patients underwent routine laboratory testing, neuroimaging, cardiac evaluation, and vascular imaging as available. Outcomes included functional status (mRS), recurrent vascular events, mortality, and return-to-work status. Predictors of poor functional outcome (mRS ≥3) were analyzed using multivariable logistic regression.

Results
Of 220 screened patients, 200 met eligibility criteria and completed the 12-month follow-up. The mean age was 36.2 ± 6.1 years, with 64% male. Hypertension (28%), dyslipidemia (20%), smoking (22%), diabetes (14%), and obesity (18%) were the most frequent vascular risk factors. Median NIHSS at presentation was 8 (IQR 5–13). Hemiparesis (76%) and speech disturbances (44%) were the most common presenting symptoms. Regarding etiology, cardioembolism was identified in 19%, large-artery atherosclerosis in 17%, small-vessel occlusion in 15%, arterial dissection in 14%, thrombophilia in 6%, vasculitis in 3%, and cryptogenic stroke in 26%.Thrombolysis was administered in 13% of patients, while no mechanical thrombectomy was performed due to limited local availability. Antiplatelet therapy was initiated in 98%, anticoagulation in 19%, and statins in 93%. In-hospital complications were uncommon, with aspiration pneumonia (5%) being the most frequent. At 12 months, 76% achieved good functional recovery (mRS 0–2), 20% had moderate-to-severe disability (mRS 3–5), and mortality was 4%. Recurrent ischemic stroke occurred in 7%, TIA in 5%, and myocardial infarction in 2%. Among patients previously employed, 80% had returned to work by one year. On multivariable analysis, baseline NIHSS >12 (OR 4.8, 95% CI 2.1–11.0) and cardioembolic etiology (OR 2.5, 95% CI 1.1–5.8) independently predicted poor long-term functional outcome.

Conclusion
Young adults with ischemic stroke in Pakistan exhibit a substantial burden of modifiable vascular risk factors and a diverse etiologic profile dominated by cardioembolic and atherosclerotic mechanisms. Despite relatively mild-to-moderate stroke severity at presentation, a significant proportion experienced persistent disability or recurrent vascular events over one year. The high prevalence of cryptogenic stroke reflects diagnostic limitations typical of resource-constrained settings. Strengthening early risk-factor detection, improving access to advanced diagnostics, and expanding stroke services—including endovascular therapy—may improve long-term outcomes for this vulnerable population. The study highlights the need for targeted prevention strategies and enhanced post-stroke rehabilitation programs to reduce the long-term socioeconomic impact of young-onset stroke.