Stroke in younger patients: the heart of the matter


Stroke in young adults is not a rare entity, and often provides difficult management decisions for neurologists. The knowledge gained from stroke in older adults does not transfer easily to this younger group given the different causes of stroke observed. Cardiac causes of stroke are common in this group, but often consist of low risk cardiac lesions such as a patent foramen ovale. Appropriate investigation should follow a stepwise approach to initially exclude higher risk pathology for recurrent stroke such as arterial dissection. Similarly, stepwise application of cardiac investigations will allow early identification of significant pathology, with investigation for abnormalities of the inter-atrial septum reserved for those with no other identified cause of stroke. Bubble contrast echo is now widely available, and with improved image quality may be performed with either transthoracic or transoesophageal echo, as well as with transcranial Doppler. Following this approach, patients can be best categorised by the expected rate of recurrent stroke, as informed by observational studies. Appropriate secondary prevention can then be tailored to the recurrence rate, with anticoagulation and possibly device closure reserved for those at highest risk of recurrence.

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Fig. 1


  1. 1.

    Note that previous classification systems (TOAST) characterised those with a PFO as cardioembolic stroke, but they are classified as cryptogenic in newer schemes, noting the presence of PFO (A-S-C-O).


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PC is funded by the National Institute of Health Research, Cambridge Biomedical Research Centre.

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Correspondence to P. E. Cotter.

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A loop is shown of a transoesophageal echo and the mid-oesophageal level. An aneurismal inter-atrial septum is seen, with a peak deviation to the left atrium of 14 mm. A Eustachian valve/Chiari network is demonstrated in the right atrium. (WMV 1321 kb)

A loop is shown of a transoesophageal bubble contract echo. Echo-lucent agitated contrast is seen passing from the superior venacava to the right atrium. It is visualised passing through a tunnel PFO from the right atrium to the left atrium, conform a right to left shunt and PFO. (MPG 1508 kb)

A loop is shown of a bubble contrast transthoracic echo. With release of Valsalva, a very large right to left shunt is observed with opacification of the left ventricle with bubbles. The early appearance of bubble in the left sided chambers (within 3 cardiac cycles) confirms an atrial level of shunting. (WMV 4781 kb)

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Cotter, P.E., Belham, M. & Martin, P.J. Stroke in younger patients: the heart of the matter. J Neurol 257, 1777–1787 (2010).

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  • Stroke
  • Cryptogenic
  • Heart
  • PFO