Spontaneous Bilateral Vertebral Artery Dissection as a Rare Cause of Posterior Circulation Stroke in a Young Patient.

In young patients, ischemic stroke is an uncommon result of vertebral artery dissection (VAD). Damage to the vertebrae can occur suddenly or as a result of trauma. There are no generally recognized recommendations for diagnosis and treatment, and the majority of vague symptoms and delayed presentation provide a significant diagnostic problem. While medical management with anticoagulant or antiplatelet therapy is advised, no successful dual therapy has been documented. Although traumatic dissection is a more frequent cause of posterior cerebral circulation stroke in people under 45 years of age than spontaneous dissection, spontaneous VAD is well-reported and usually treated with anticoagulation. VAD can result in fatal complications such as basilar area infarction, even though it is often asymptomatic. Here is a case of a 37-year-old male who presented with a posterior circulation stroke after bilateral VAD with no evidence of trauma to the neck and no detectable cause suggesting spontaneous etiology.

Altered fibrin clot phenotype in young adults with intracerebral hemorrhage of unknown cause: A case-control study.

BACKGROUND: Intracerebral hemorrhage (ICH) of undetermined etiology occurs infrequently in young and middle-aged adults. We hypothesized that slight decreases in coagulation factors and formation of less compact fibrin clots prone to faster lysis predispose to this type of ICH. METHODS: We recruited 44 consecutive patients aged <50 years following ICH of unknown cause at least 3 months since the event. Subjects free of ICH (n = 47) matched for age, sex, BMI, and hypertension served as the control group. We assessed plasma fibrin clot permeability, turbidity and fibrinolytic capacity, along with thrombin generation, coagulation factors (F) II, FV, FVII, FVIII, FIX, FX, FXI, antithrombin, and fibrinolysis proteins. RESULTS: ICH patients (median age 41 years, 45.5 % women) had 8.4 % lower FII (p = 0.0001) and 10.1 % lower FVII activity (p = 0.0003), 9.4 % higher antithrombin activity (p = 0.0004) and 13.5 % lower platelet count (p = 0.02). Other factors and thrombin generation did not differ between the two groups. The ICH survivors were characterized by impaired fibrin polymerization reflected by 10.1 % longer lag phase of the turbidimetry curve (p = 0.0002), decreased fiber density indicated by 11.8 % lower maximum absorbance (p = 0.004), as well as 11.1 % shorter clot lysis time (p = 0.014) and 10.0 % faster increase of maximal D-Dimer levels (p = 0.000001). CONCLUSIONS: We demonstrated a prohemorrhagic fibrin clot phenotype, along with lower FII, FVII and higher antithrombin activity in adults below 50 years of age who suffered from ICH of unknown cause, which might indicate novel mechanisms contributing to ICH in younger individuals.

A Young Female Newly Diagnosed With Takayasu's Arteritis Masquerading As Cerebrovascular Stroke.

The condition known as Takayasu's disease or Takayasu's arteritis is a type of vascular inflammation that affects the large and medium arteries. It can lead to a reduction in blood flow to various parts of the body, and it can cause severe complications. Patients with this disease may not have specific symptoms, which can lead to their diagnosis not being confirmed. Takayasu's disease is believed to be a probable cause of stroke in young patients. Although stroke is a common cause of morbidity, it is usually not an initial presentation in Takayasu's disease. In this study, a young female with left-sided hemiparesis was diagnosed with Takayasu's disease after a clinical and angiographic examination.

Declining first-ever stroke incidence rates in 15- to 54-year-old residents of Tartu, Estonia, from 1991 to 2017.

BACKGROUND: Having a stroke at a young age has a huge socioeconomic impact. Data on the trends of stroke incidence in young adults from prospective population-based studies are scarce. AIMS: The aim of this study was to analyze the trends in stroke incidence in 15- to 54-year-old residents of Tartu, Estonia from 1991 to 2017. METHODS: Three population-based studies with identical study protocols determining the incidence of first-ever stroke have previously been conducted in Tartu, Estonia (1991-1993, 2001-2003, and 2013-2017). All residents of Tartu with first-ever stroke (ischemic stroke, spontaneous intracerebral hemorrhage, and subarachnoid hemorrhage) who were hospitalized to the Department of Neurology, Tartu University Hospital in respective study periods were included prospectively. Overlapping data sources for case ascertainment were used to include both hospitalized and non-hospitalized cases. Trends in first-ever stroke incidence in 15- to 54-year-old residents of Tartu were calculated and compared using rate ratio (RR). RESULTS: Altogether 259 strokes were identified. From 1991 to 2017, the proportion of women increased from 38.3% to 43.6%. Mean age at onset in women decreased from 46.9 (standard deviation (SD): 7.3) to 42.6 (SD: 8.9). Overall crude incidence rates per 100,000 decreased significantly from 1991 to 2003 (from 57.2 (95% confidence interval (CI): 46.9-69.1) to 35.7 (95% CI: 25.7-48.3)); RR: 0.62 (95% CI: 0.44-0.89). While also present in women, the decrease was most notable in 45- to 54-year-old men (RR: 0.55 (95% CI: 0.30-0.99)). In 35- to 44-year-old men, the incidence rates decreased significantly from 2001 to 2017 (RR: 0.37 (95% CI: 0.14-0.99)). CONCLUSION: The overall first-ever stroke incidence rates decreased from 1991 to 2003 and remained stable thereafter.

HIV infection and stroke in the Young in Abuja, Nigeria: a case series.

Stroke is a major cause of disability and mortality among the Nigerian general population and thought to be commoner after the fifth decade of life and usually driven by conventional risk factors which are mainly cardio metabolic. However, with the youthful population in a city such as Abuja, stroke could be a mode of presentation of HIV in young people who are also more sexually active. Methods. This is a case series, reporting four cases of HIV positive young Nigerians with stroke. Patients´ data were retrieved from ward admissions records. The patients here had their socio-demographic data taken. They had presented with documented varied clinical features including those suggestive of stroke, after which they had HIV screening done which returned positive. One thousand four hundred and eighty-seven (1487) patients, were admitted in the medical ward, over a three-year period. Female to male ratio of 1:1 in the HIV-positive group, with an age range of 32 to 42 years and an average age of 37.5 years. Stroke constituted 5.7% of all admissions, with stroke in the young accounting for 1.2%. Of all stroke cases, stroke in the young constituted 21.43%, with those who were HIV positive accounting for 4.8%. Young people with stroke should be offered an HIV screening test.

Post-coital internal carotid artery dissection associated with acute cerebral infarction in a Filipino female: A case report

@#Carotid arterial dissections may result from spontaneous or traumatic causes. Postcoital arterial dissections have been reported in both the vertebral and coronary arteries. We report a rare case of spontaneous dissection on the extracranial internal carotid artery in a Filipino female after sexual intercourse, leading to a fulminant middle cerebral artery (MCA) territory infarct. Although postcoital carotid artery dissection is a very rare cause of neck vessel dissections, its rapid progressive course can lead to massive cerebral infarction and prompt management must be initiated.

'More Than Just Skin in the Game'. DADA2 Autoinflammatory Syndrome and Stroke in the Young.

A 21-year-old man had a long-standing history of leg ulcers and hyperpigmention over the feet. Over a span of 8 months, he had an acute ischemic stroke followed by a basal ganglia hemorrhage. He was finally diagnosed with DADA2 syndrome after genetic sequencing. The implications of this new syndrome and its links to stroke in the young are presented in this article.

The Intracerebral Hemorrhage Score Overestimates Mortality in Young Adults.

OBJECTIVE: To determine whether the intracerebral hemorrhage (ICH) score is accurate in predicting 30-day mortality in young adults, we calculated the ICH score for 156 young adults (aged 18-45) with primary spontaneous ICH and compared predicted to observed 30-day mortality rates. METHODS: We retrospectively reviewed all patients aged 18-45 consecutively presenting to the University of Iowa from 2009 to 2019 with ICH. We calculated the ICH score and recorded its individual subcomponents for each patient. Poisson regression was used to test the association of ICH score components with 30-day mortality. RESULTS: We identified 156 patients who met the inclusion criteria; mean± standard deviation (SD) age was 35±8 years. The 30-day mortality rate was 15% (n=24). The ICH score was predictive of 30-day mortality for each unit increase (p= 0.04 for trend), but the observed mortality rates for each ICH score varied considerably from the original ICH score predictions. Most notably, the 30-day mortality rates for ICH scores of 1, 2, and 3 are predicted to be 13%, 26%, and 72% respectively, but were observed in our population to be 0%, 3%, and 41%. An ICH volume of >30cc [relative risk (RR) 28, 95% confidence intervals (CI) 3-315, p=0.01] and a GCS score of <5 (RR 13, 95% CI 0.1-1176, p=0.01) were independently associated with 30-day mortality. CONCLUSIONS: The ICH score tends to overestimate mortality in young adults. ICH volume and GCS score are the most relevant items in predicting mortality at 30 days in young adults.

Baseline Characteristics of Patients with Symptomatic Carotid Webs: A Matched Case Control Study.

BACKGROUND AND PURPOSE: The baseline characteristics of patients with symptomatic carotid web (CaW) are unclear. We investigate demographic and cerebrovascular risk factors in patients with this overlooked stroke etiology. METHODS: We identified consecutive patients diagnosed with symptomatic CaW at a comprehensive stroke center from July 2014-December 2018. These patients were matched at a 1:4 ratio (based on age and NIHSS scores) to create a control group of acute ischemic stroke (AIS) patients with non-CaW etiologies from the local GetWithTheGuidelines stroke database. RESULTS: Thirty patients with symptomatic CaW were compared to 120 AIS patients with non-CaW etiologies. Symptomatic CaW patients were more likely to be female (73.3 vs. 44.2%; p = 0.004) and black (86.7 vs. 64.2%; p = 0.02). Symptomatic CaWs patients had a fewer absolute number of modifiable cerebrovascular risk factors (1.7±1.1 vs. 2.5±1.2; p = 0.002), lower rates of hypertension (43.4 vs. 63.3%; p = 0.04), and a more favorable lipid profile with lower average LDL (89.5±30.3 vs. 111.2±43.7 mg/dL; p = 0.01) and higher average HDL (47.9±11.3 vs. 42.2±13.8 mg/dL; p = 0.01) as compared to strokes with non-CaW etiology. Symptomatic CaW patients were more likely to have a large vessel occlusion (80.0 vs. 51.7%; p = 0.005), despite similar e-ASPECTS between the groups (8.1±2.1 vs. 8.3±2.2; p = 0.30). On multivariable analysis, symptomatic CaW was an independent predictor of independence at discharge (OR 3.72; 95%CI 1.27-10.94). CONCLUSION: A gender and racial predilection of symptomatic CaWs may exist as females and blacks were were found to be more likely affected. Symptomatic CaW patients have a more benign cerebrovascular risk factor profile corroborating the proposed mechanism of local stasis and thromboembolism. Despite presenting more commonly with LVO, symptomatic CaW was associated with good functional outcome, warranting further studies.

Increasing false positive diagnoses may lead to overestimation of stroke incidence, particularly in the young: a cross-sectional study.

BACKGROUND: Stroke incidence is reportedly increasing in younger populations, although the reasons for this are not clear. We explored possible reasons by quantifying trends in neurologically focused emergency department (ED) visits, classification of stroke vs. TIA, and imaging use. METHODS: We performed a retrospective, serial, cross-sectional study using the National Hospital Ambulatory Medical Care Survey to examine time trends in age-stratified primary reasons for visit, stroke/TIA diagnoses, and MRI utilization from 1995 to 2000 and 2005-2015. RESULTS: Five million eight hundred thousand ED visits with a primary diagnosis of stroke (CI 5.3 M-6.4 M) were represented in the data. The incidence of neurologically focused reason for visits (Neuro RFVs) increased over time in both the young and in older adults (young: + 111 Neuro RFVs/100,000 population/year, CI + 94 - + 130; older adults: + 70 Neuro RFVs/100,000 population/year, CI + 34 - + 108). The proportion of combined stroke and TIA diagnoses decreased over time amongst older adults with a Neuro RFV (OR 0.95 per year, p < 0.01, CI 0.94-0.96) but did not change in the young (OR 1.00 per year, p = 0.88, CI 0.95-1.04). Within the stroke/TIA population, no changes in the proportion of stroke or TIA were identified. MRI utilization rates amongst patients with a Neuro RFV increased for both age groups. CONCLUSIONS: We found, but did not anticipate, increased incidence of neurologically focused ED visits in both age groups. Given the lower pre-test probability of a stroke in younger adults, this suggests that false positive stroke diagnoses may be increasing and may be increasing more rapidly in the young than in older adults.

Differences in healthcare visit frequency and type one year prior to stroke among young versus middle-aged adults.

BACKGROUND: The incidence and prevalence of stroke among the young are increasing in the US. Data on healthcare utilization prior to stroke is limited. We hypothesized those < 45 years were less likely than those 45-65 years old to utilize healthcare in the 1 year prior to stroke. METHODS: Patients 18-65 years old who had a stroke between 2008 and 2013 in MarketScan Commercial Claims and Encounters Databases were included. We used descriptive statistics and logistic regression to examine healthcare utilization and risk factors between age groups 18-44 and 45-65 years. Healthcare utilization was categorized by visit type (no visits, inpatient visits only, emergency department visits only, outpatient patient visits only, or a combination of inpatient, outpatient or emergency department visits) during the year prior to stroke hospitalization. RESULTS: Of those 18-44 years old, 14.1% had no visits in the year prior to stroke compared to 11.2% of individuals aged 45-65 [OR = 1.30 (95% CI 1.25,1.35)]. Patients 18-44 years old had higher odds of having preventive care procedures associated with an outpatient visit and lower odds of having cardiovascular procedures compared to patients aged 45-65 years. Of stroke patients aged 18-45 and 45-65 years, 16.8 and 13.2% respectively had no known risk for stroke. CONCLUSIONS: Patients aged 45-65 were less commonly seeking preventive care and appeared to be seeking care to manage existing conditions more than patients aged 18-44 years. However, as greater than 10% of both age groups had no prior risk, further exploration of potential risk factors is needed.

Acute ischaemic stroke in the absence of established vascular risk factors: Patient characteristics, stroke mechanism and long-term outcome.

BACKGROUND AND PURPOSE: Some acute ischaemic stroke (AIS) patients do not display established vascular risk factors (EVRFs). The aim was to assess their clinical characteristics, stroke subtype etiological classification and long-term outcome. METHODS: All consecutive AIS patients from the Acute Stroke Registry of Lausanne (2003-2018) were retrospectively analyzed with complete assessment of the following EVRFs: hypertension, diabetes, major cardioembolic sources, dyslipidemia, smoking, obesity, alcohol abuse, previous stroke/transient ischaemic attack and depression/psychosis. Patients without EVRFs were compared to patients with one or more EVRFs using appropriate statistical models. RESULTS: Of 4889 included patients, 103 (2.1%) had no EVRFs. In multiple regression analysis, patients without EVRFs were significantly younger (odds ratio [OR] 0.13; 95% confidence interval [CI] 0.08-0.20) and had more multiterritorial strokes (OR 3.38; 95% CI 1.26-9.05). Strokes were more often related to patent foramen ovale (PFO) (OR 3.02; 95% CI 1.44-6.32) and less to atherosclerosis, cardioembolism or small vessel disease. In patients <55 years old, PFO (OR 2.76; 95% CI 1.50-5.08) and contraceptive use in females (OR 2.75; 95% CI 1.40-5.41) were more frequent, whereas sleep apnea syndrome (OR 0.09; 95% CI 0.01-0.63) was less. In patients ≥55 years, female sex (OR 2.84; 95% CI 1.43-5.65) and active cancer (OR 3.27; 95% CI 1.34-7.94) were more prevalent. At 12 months, patients without EVRFs had worse adjusted functional outcome (Rankin shift ORadj 0.63; 95% CI 0.42-0.95) and higher rate of recurrence and death (adjusted hazard ratio 2.11; 95% CI 1.19-3.74). CONCLUSIONS: In a consecutive cohort of AIS patients, only 2% showed no EVRFs. PFO and contraceptive use exhibited a strong association with the absence of EVRFs in younger patients and female sex and active cancer in elderly patients. Our findings highlight the importance of searching for previously unknown risk factors and/or unusual stroke mechanisms in patients without EVRFs.

Fabry disease patients have an increased risk of stroke in the COVID-19 ERA. A hypothesis.

Stroke is a severe and frequent complication of Fabry disease (FD), affecting both males and females. Cerebrovascular complications are the end result of multiple and complex pathophysiology mechanisms involving endothelial dysfunction and activation, development of chronic inflammatory cascades leading to a prothrombotic state in addition to cardioembolic stroke due to cardiomyopathy and arrhythmias. The recent coronavirus disease 2019 outbreak share many overlapping deleterious pathogenic mechanisms with those of FD and therefore we analyze the available information regarding the pathophysiology mechanisms of both disorders and hypothesize that there is a markedly increased risk of ischemic and hemorrhagic cerebrovascular complications in Fabry patients suffering from concomitant SARS-CoV-2 infections.

Left Atrial Function in Young Patients With Cryptogenic Stroke and Patent Foramen Ovale: A Left Atrial Longitudinal Strain Study.

Background: The study of left atrial (LA) longitudinal strain by speckle tracking is a reliable method for analyzing LA function that could provide relevant information in young patients with cryptogenic stroke (CS). The aim of this study was to investigate whether the presence of a patent foramen ovale (PFO) impacts the LA longitudinal strain in a population of young patients with first CS. Methods and Results: Patients aged 18 to 54 years, treated consecutively in a university hospital for first CS, were included in this study. The presence of a PFO and an atrial septal aneurysm (ASA) was investigated using transesophageal echocardiography and transcranial Doppler. Speckle tracking analysis was performed on transthoracic echocardiography, allowing the measurement of global, passive, and active longitudinal LA strain, corresponding to the reservoir, conduit, and contractile function, respectively. A total of 51 patients were included in the study. In a multivariable analysis, overweight was associated with reduced global and passive LA longitudinal strain (P = 0.013 and P = 0.018, respectively), and hypertension was associated with reduced active LA longitudinal strain (P = 0.049). LA longitudinal strain was not different between patients with PFO or PFO plus ASA and patients without PFO. Conclusion: LA longitudinal strain in young subjects with CS was impaired in the presence of overweight and hypertension, but not of PFO or PFO plus ASA.

Index Admission Characteristics and All-Cause Readmissions Analysis in Younger and Older Adults with Intracerebral Hemorrhage.

INTRODUCTION: Intracerebral hemorrhage (ICH) comprises 15-20% of all strokes with debilitating consequences. Data regarding characteristics and outcomes of primary ICH in the young are lacking, given its rarity, making comparisons between younger and older cohorts difficult to perform. Nationally representative administrative databases enable analysis of such rare events. OBJECTIVE: To determine the baseline characteristics, all-cause readmission rates, and reasons for primary ICH in younger and older adults using a nationally representative database. METHODS: A retrospective cohort analysis was performed using the Nationwide Readmissions Database 2013. Validated ICD-9-CM codes identified index ICH admissions, comorbidities, demographics, behavioral risk factors, procedures, and Elixhauser and Charlson Comorbidity indices. We compared "younger" (age ≤ 45 years) and "older" (age > 45) index ICH admissions by weighted 30-day all-cause readmission rates, primary diagnosis code for 30-day readmissions, most common comorbidities during the index hospitalization, and Kaplan-Meier cumulative risk of readmission up to 1 year. RESULTS: Older admissions had higher comorbidity scores and mortality, but both groups had similar total comorbidities. Younger admissions exhibited longer length of stay with more procedures performed. Vascular anomalies (aneurysm 7.2 vs. 4.6% and arteriovenous malformation 5.9 vs. 0.8%) and behavioral risk factors (smoking 26.5 vs. 23.0%, alcohol abuse 6.7 vs. 4.6%, and substance use 13.5 vs. 2.9%) were more prevalent in younger admissions, while older patients had more cardiovascular comorbidities. All-cause 30-day readmission rates (13.1 vs. 13.0%) and 1-year cumulative risk of readmission (log-rank p value 0.7209) were similar. Readmissions in the younger cohort were primarily for neurological conditions, and those in the older cohort were for systemic conditions. CONCLUSIONS: Adults <45 years with ICH had similar total comorbidities as older adults but more procedures, longer hospital stay, and more behavioral risk factors. Readmission rates were similar though reasons differed; younger patients were more for neurological reasons than for other systemic causes.

Migraine, low-dose combined hormonal contraceptives, and ischemic stroke in young women: a systematic review and suggestions for future research.

Introduction: Migraine and combined hormonal contraceptives (CHCs) increase the risk of ischemic stroke in young women; however, the contribution of low-dose (<50 µg ethinylestradiol) CHCs to the risk of ischemic stroke in young women with migraine is not well defined.Areas covered: The authors performed a systematic review of observational studies indexed in PubMed and Scopus from inception to 22 May 2019, reporting the effect sizes of ischemic stroke in women with migraine using low-dose CHCs compared with those without migraine not using CHCs. All the four included case-control studies, including a total of 12,256 women, reported increased odds of ischemic stroke in women with migraine and low-dose CHC use compared with those without migraine not using CHCs. A meta-analysis was not feasible due to significant heterogeneity.Expert opinion: Strong data on the joint effect of migraine and CHC use on risk of ischemic stroke are lacking especially referring to the role of aura and headache frequency. Evidence suggests that the association with ischemic stroke is driven by migraine with aura. More robust data are needed to assess whether CHCs remain viable for women with migraine without aura, and whether their use could extend to some women with migraine with aura.

Premature vascular disease in young adult stroke: a pathology-based case series.

INTRODUCTION: The prevalence of modifiable vascular risk factors is increasing in young adults and may contribute to the growing frequency of stroke in this population. The neuropathology and end-organ damage profile of young adult stroke patients with clinically advanced atherosclerosis or arteriosclerosis has not been studied. METHODS: This retrospective study included patients aged 18-60 years admitted to our hospital from 1995 to 2017 with recurrent ischemic or hemorrhagic strokes, fatal stroke, or stroke associated with advanced small vessel disease (SVD) on brain MRI, who had no evidence for structural, genetic, inflammatory, or infectious etiology for stroke, and had adequate pathological materials available for analysis. The presence of atherosclerosis, arteriolosclerosis, left ventricular hypertrophy, and nephrosclerosis was evaluated. RESULTS: Twelve patients (mean age 47 ± 9 years, range 31-57 years, 67% male) met inclusion criteria. Four had fatal intracerebral hemorrhage (ICH), three had recurrent non-fatal ICH, one had ICH with advanced SVD on MRI, and four had recurrent ischemic strokes including two with transient ischemic attacks. Pathological studies showed moderate/severe atherosclerosis in 64% and moderate/severe arteriolosclerosis in 42% of patients. Pathological data to evaluate end-organ damage were available for nine patients; eight showed left ventricular hypertrophy and all showed nephrosclerosis. CONCLUSION: Young adult stroke patients with recurrent stroke, fatal stroke, or SVD on imaging have advanced atherosclerosis and arteriolosclerosis-related pathological changes in multiple organ systems. Aggressive control of atherosclerosis risk factors is warranted even in young individuals.

Left Ventricular Thrombus: An Interesting Presentation of Primary Antiphospholipid Antibody Syndrome with a Mini-review of the Literature.

Antiphospholipid syndrome (APLS) is characterized by recurrent thrombosis. We report the case of a 36-year-old male who had acute right-sided ischemic stroke and right leg ischemia secondary to left ventricular (LV) thrombus caused by primary APLS. The literature review suggested that the LV thrombus presented most commonly with systemic embolism and was associated with a mortality rate of 22.2% with treatment. Thrombophilic workup in young patients with a systemic thromboembolic episode (s) is advised.

"Basilar Web" Causing Basilar Branch Infarction.

We present a young patient with no vascular risk factors with a basilar branch infarction secondary to a shelf-like filling defect of the basilar artery. This defect was present and unchanged on repeat imaging and determined to be most consistent with a basilar web. Similar to carotid webs, a basilar web is believed to be an area of focal intimal fibroplasia that increases the risk of brainstem infarction. Focal fibroplasia of the posterior circulation should be considered when evaluating young adults with posterior circulation strokes of otherwise undetermined cause.

A Stroke in the Young with Surprising Recovery.

INTRODUCTION: The differential diagnosis of stroke in a comparatively young adult should always include cardiovascular aetiologies as well as central nervous system infection. CASE PRESENTATION: A 56-year-old man, with no significant medical history, presented with headache, nausea and vomiting, and right hemiparesis. Routine stroke investigation was initiated, while CNS infection was also sought. Diagnoses of HIV infection, neurosyphilis, HCV and HBV were established. Targeted therapy resulted in prompt clinical improvement. CONCLUSION: This case highlights the importance of considering CNS infection as a cause of neurological deficits in parallel with other investigations in cases of stroke in a comparatively young adult. LEARNING POINTS: The differential diagnosis should be wide for all patients presenting with stroke.Neurosyphilis should be included in the differential diagnosis of stroke in the young and middle-aged.Newly diagnosed HIV patients should be screened for other, sexually transmitted coinfection.