1. Malignancy-Stroke Axis: Consider active/occult cancer as an etiology for stroke in patients without vascular risk factors. Think about hypercoagulability and nonbacterial thrombotic endocarditis.

 

2. Cervical/carotid artery dissections are leading causes of stroke in young patients. A tear in the intimal layer (trauma, chiropractic manipulation) creates a false lumen that can thrombose or embolize. Patients present with headache or neck pain followed by neurological deficits.

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3. Cardioembolism: Characterized by sudden-onset, high-NIHSS deficits in multiple vascular territories. Look for atrial fibrillation on the EKG and think about recent MI or prosthetic heart valves.

 

4. Patent foramen ovale/ASD:  A paradoxical embolism crosses from the right to the left atrium via the PFO/ASD. Consider this in young patients without traditional risk factors. Further workup includes echo, bubble study and transesophageal echo. There are now broader guidelines for closure.

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5. Sympathomimetic Toxicity: Cocaine and methamphetamines cause strokes via acute hypertensive surges,  leading to ICH and profound vasospasm leading to ischemia.