Rarer causes of ischaemic stroke

Consider uncommon causes of stroke in young patients without traditional vascular risk factors. Refer to a stroke physician. No cause is identified in about 40% of young patients with ischaemic stroke, despite extensive investigation.

Rarer causes of ischaemic stroke are listed below.

• Bacterial endocarditis. Consider this in patients with a stroke, signs of infection (eg fever, night sweats) and cardiac murmur (this may be absent). See management. Anticoagulants are contraindicated.
• Cerebral venous thrombosis. This has several clinical manifestations. Acutely, it can present as a stroke, often with seizures and a haemorrhagic infarct on computed tomography (CT). Diagnosis is by CT or magnetic resonance venography. Usually the patient is given heparin as an anticoagulant during the acute phase of the stroke, even if they have a cerebral haemorrhage. After the acute phase the patient is given warfarin for 6 months, or longer if they have a clotting disorder. Expert management by a stroke physician and haematologist is recommended.
• Carotid or vertebrobasilar arterial dissection. This can be spontaneous or due to neck trauma (even minor). It can present with neck pain, headache, Horner syndrome, or ischaemic stroke due to thromboembolism. Neuroimaging confirms the diagnosis. Recurrence is rare, and evidence shows no superiority of anticoagulation over antiplatelet therapy as secondary prevention.
• Patent foramen ovale. This is a common finding in young patients with stroke, but management is controversial. Seek expert advice.