Stroke in the Young: Shifting Epidemiology, Aetiological Breadth, and the Case for a Structured, Equity-Conscious Diagnostic Approach: A Narrative Review

Background: Ischaemic stroke in young adults, usually taken to mean the years between 18 and 50, has long been regarded as a marginal corner of cerebrovascular disease. That view is now hard to sustain. Agestandardised rates have indeed fallen among older people; in the young they have held flat or risen across many high-income settings, and the absolute global burden keeps climbing, most steeply in low and lowermiddle income regions. Summary of review: This review draws together current evidence on the epidemiology, causes, diagnostic evaluation, and secondary prevention of ischaemic stroke in young adults. The causes are varied and shift with age. Cervical artery dissection, patent foramen ovale with paradoxical embolism, premature atherosclerosis fed by a rising burden of early-onset vascular risk factors, monogenic arteriopathies, prothrombotic and inflammatory disorders, and the mechanisms peculiar to pregnancy all warrant consideration, and yet a sizeable share of cases still defies classification. We set out an original tiered diagnostic algorithm, weigh the randomised evidence behind patent foramen ovale closure and the place of the RoPE score, and examine what remains unsettled in cervical artery dissection and in embolic stroke of undetermined source. Conclusions: What most often decides outcome in young stroke is not a shortage of effective treatment. More commonly it is a failure of recognition, of complete investigation, and of fair access to the treatments that already exist. A disciplined, phenotype-driven work-up, genuine attention to the psychosocial and occupational toll carried by survivors, and a deliberate effort to narrow gaps in diagnostic access together offer the most realistic route to better outcomes in this group.