APPROACH TO
YOUNG STROKE
Aetiology · Workup · Imaging Patterns
Based on: Malaysian CPG Stroke (2020) · ESO Guidelines (2021) · AHA/ASA (2021) · UpToDate
Presented by: Rupinder Kaur
,Case Presentation
PATIENT DETAILS
• 20-year-old Indian male
Motor — Power:
• Active smoker • Right UL and LL: 5/5 (full)
• Work as aircon technician, single • Left UL: 4/5 Left LL: 5/5
• Previously well, NKMI • Reflexes, Sensation, Tone: Intact
• Presented: 15 January 2026 • Babinski: downgoing bilaterally
• Woke at 0600h with left facial asymmetry,
slurred speech, left upper limb weakness NIHSS:
• Initial 0917h: NIHSS 3
• Last seen well: 2300h on 14/1/2026
(complete hemianopia, minor paralysis)
On Arrival:
• GCS: E4V5M6 Pupils: 3/3 reactive, Left facial asymmetry,
hemianopia
• BP 127/84 PR 77 SpO2 98% RA
• Temp 37°C DXT 6.6 mmol/L
• Chest clear, CVS dual rhythm, Abdomen soft
,Initial Assessment, Imaging & Acute Management
15–16 January 2026
ASSESSMENT IMAGING MANAGEMENT
• Stroke protocol activated 15.1.26 AT CT Stroke Protocol AT 1000H: • IV thrombolysis Alteplase given
0915h • Acute right MCA infarct BW 75kg (67mg given at 1107H)
• NIHSS: 3 • Right proximal M1 occlusion • Mechanical thrombectomy :
• Good vascular collaterals Cerebral angiogram done
• CT perfusion: large penumbra Right ICA angiogram showed patent
-
right ICA and right MCA
• ASPECTS score: 6 The occlusion seen in CT no longer
• Eligible for IV thrombolysis visualised. The right ACA is supplied
solely by the left ICA and the
anterior communicating artery
Reassessment 1100h: NIHSS 8 Thus not proceeded with
(hemianopia, hemiparesis, dysarthria, thrombectomy in view of
partial sensory loss, inattention) recanalization of Right MCA post
thrombolysis
NIHSS 2 H post thrombolysis : 8
Power Left UL : 4/5, Left LL 5
• Admitted under stroke team
• Standard stroke bundle care
, Laboratory & Autoimmune Workup
Comprehensive screening — no systemic cause identified on initial panel
AUTOIMMUNE & INFLAMMATORY METABOLIC & OTHER
• C3: 1.97 C4: 0.31 (normal) Glycaemic:
• ESR: 17 mm/hr • HbA1c: 5.3% (no diabetes)
• TSH: 3.93 T4: 15.8
• Hepatitis B & C: non-reactive Lipids:
VDRL Negative • TC 4.5 HDL 0.8 LDL 2.9 TG 1.9
Pending results: Renal & Liver:
• Anticardiolipin antibodies Lupus Anticoagulant Pending • Within acceptable limits
Beta 2 Glycoprotein and Anti Cardiolipin Negative
• ANA Negative , ENA, anti-dsDNA- Not send
Serum Homocysteine level rejected
YOUNG STROKE
Aetiology · Workup · Imaging Patterns
Based on: Malaysian CPG Stroke (2020) · ESO Guidelines (2021) · AHA/ASA (2021) · UpToDate
Presented by: Rupinder Kaur
,Case Presentation
PATIENT DETAILS
• 20-year-old Indian male
Motor — Power:
• Active smoker • Right UL and LL: 5/5 (full)
• Work as aircon technician, single • Left UL: 4/5 Left LL: 5/5
• Previously well, NKMI • Reflexes, Sensation, Tone: Intact
• Presented: 15 January 2026 • Babinski: downgoing bilaterally
• Woke at 0600h with left facial asymmetry,
slurred speech, left upper limb weakness NIHSS:
• Initial 0917h: NIHSS 3
• Last seen well: 2300h on 14/1/2026
(complete hemianopia, minor paralysis)
On Arrival:
• GCS: E4V5M6 Pupils: 3/3 reactive, Left facial asymmetry,
hemianopia
• BP 127/84 PR 77 SpO2 98% RA
• Temp 37°C DXT 6.6 mmol/L
• Chest clear, CVS dual rhythm, Abdomen soft
,Initial Assessment, Imaging & Acute Management
15–16 January 2026
ASSESSMENT IMAGING MANAGEMENT
• Stroke protocol activated 15.1.26 AT CT Stroke Protocol AT 1000H: • IV thrombolysis Alteplase given
0915h • Acute right MCA infarct BW 75kg (67mg given at 1107H)
• NIHSS: 3 • Right proximal M1 occlusion • Mechanical thrombectomy :
• Good vascular collaterals Cerebral angiogram done
• CT perfusion: large penumbra Right ICA angiogram showed patent
-
right ICA and right MCA
• ASPECTS score: 6 The occlusion seen in CT no longer
• Eligible for IV thrombolysis visualised. The right ACA is supplied
solely by the left ICA and the
anterior communicating artery
Reassessment 1100h: NIHSS 8 Thus not proceeded with
(hemianopia, hemiparesis, dysarthria, thrombectomy in view of
partial sensory loss, inattention) recanalization of Right MCA post
thrombolysis
NIHSS 2 H post thrombolysis : 8
Power Left UL : 4/5, Left LL 5
• Admitted under stroke team
• Standard stroke bundle care
, Laboratory & Autoimmune Workup
Comprehensive screening — no systemic cause identified on initial panel
AUTOIMMUNE & INFLAMMATORY METABOLIC & OTHER
• C3: 1.97 C4: 0.31 (normal) Glycaemic:
• ESR: 17 mm/hr • HbA1c: 5.3% (no diabetes)
• TSH: 3.93 T4: 15.8
• Hepatitis B & C: non-reactive Lipids:
VDRL Negative • TC 4.5 HDL 0.8 LDL 2.9 TG 1.9
Pending results: Renal & Liver:
• Anticardiolipin antibodies Lupus Anticoagulant Pending • Within acceptable limits
Beta 2 Glycoprotein and Anti Cardiolipin Negative
• ANA Negative , ENA, anti-dsDNA- Not send
Serum Homocysteine level rejected
