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STROKE SERIES · ARTICLE 11 OF 12
Stroke in special cases
Young adults, pregnancy, HIV, AFib, sickle cell.
Most strokes happen in older adults with the standard pattern of risk factors — high BP, diabetes, cholesterol, smoking. Articles 4, 8, 9 and 10 of this series are about those patients. But about one in five South African strokes happens in someone under 50, or in someone whose risk picture doesn't fit the standard. The investigation and the management of those strokes is different, and lay information about them is hard to find.
This article covers the special cases: stroke in young adults, stroke in pregnancy and post-partum, stroke in HIV, AFib in more detail than article 10 had space for, stroke in sickle cell disease, and the unusual causes that get bundled under “cryptogenic” stroke — including carotid dissection, patent foramen ovale, and inherited clotting disorders.
A note on this article
Each of these special cases really deserves its own deeper article. We have given the essentials here. Patients and families dealing with any of these should expect their stroke specialist to spend time on the specifics — and should ask questions until they understand.
Stroke in young adults — under 50
About 20% of South African strokes happen in people under 50. The pattern is different from older patients. In young stroke patients, the standard risk factors (high BP, diabetes, cholesterol) account for less than half of cases. The rest are spread across a long list of less common causes.
What investigations are usually done
For a young patient with no obvious cause, the workup typically includes:
• Detailed brain imaging (MRI as well as CT).
• Imaging of the neck and brain arteries (CT or MR angiography) — looking for carotid dissection, vasculitis.
• Heart imaging (echocardiogram, sometimes a “bubble study” to look for a patent foramen ovale).
• Extended heart rhythm monitoring (sometimes 48 hours, sometimes a small implant for months) — looking for hidden AFib.
• Detailed blood tests — clotting factors, autoimmune markers, sometimes genetic studies.
• HIV test and viral load (if HIV-positive).
• Lupus and anti-phospholipid antibody screen.
• Sometimes a lumbar puncture if vasculitis or infection is suspected.
The common diagnoses
• Cryptogenic stroke — no cause found after full workup. About 25% of young strokes.
• Carotid or vertebral artery dissection — see below.
• Patent foramen ovale (PFO) — see below.
• Combined contraceptive pill + other factors — see below.
• Illicit drug use — particularly cocaine and methamphetamine (“tik”).
• Inherited clotting disorders — Factor V Leiden, protein C/S deficiency, antithrombin deficiency.
• Autoimmune conditions — lupus, antiphospholipid syndrome, vasculitis.
• HIV-related vasculopathy.
• Sickle cell disease.
• Migraine with aura — rare cause but a known risk factor, especially with smoking.
• Severe hyperhomocysteinaemia — usually due to vitamin B12 or folate deficiency.
Carotid and vertebral artery dissection
A tear in the inner lining of one of the major arteries supplying the brain. Blood gets into the wall of the artery, creates a flap, and either narrows the artery or triggers a clot that travels into the brain. Most common in adults under 50.
Causes
• Sudden neck movement (whiplash from a car accident, neck manipulation, sometimes during sports or even a violent cough).
• Sometimes no cause at all — spontaneous dissection.
• Some patients have an underlying connective tissue weakness (Marfan or Ehlers-Danlos syndrome).
Clues
• Neck pain, often unilateral.
• Headache.
• Sometimes a small drooping eyelid and a small pupil on the same side as the pain (Horner's syndrome).
• Stroke or TIA symptoms.
Treatment
Usually 3 – 6 months of anti-platelet or anticoagulant therapy while the artery heals. Most cases recover well. Stroke from dissection has a lower recurrence rate than other causes once the dissection has healed.
Patent foramen ovale (PFO)
A small hole between the two upper chambers of the heart that normally closes shortly after birth. About 1 in 4 adults have a PFO that remains open. Most of the time it causes no problems. Sometimes it allows a small clot from the leg veins to slip into the brain circulation — a “paradoxical embolism” — and cause a stroke.
PFO is suspected when:
• A young patient has a stroke with no other cause found.
• A “bubble study” echocardiogram shows the hole.
Treatment options after a stroke with a documented PFO and no other cause:
• Anti-platelet therapy alone for low-risk PFOs.
• PFO closure (a small catheter procedure that plugs the hole) for selected patients — strongly considered in young patients with no other identified cause.
• Anticoagulation in some cases.
PFO closure is available at major SA cardiology centres including UCT Heart Hospital, Charlotte Maxeke, Steve Biko, and several private hospital groups.
Stroke in pregnancy and post-partum
Pregnancy roughly triples stroke risk, with the highest-risk period being the first 6 weeks after delivery. About 30 cases per 100 000 pregnancies — uncommon but serious.
What raises the risk
• Pre-eclampsia and eclampsia — the biggest contributor. BP Series Article 11 covers this.
• Caesarean delivery, particularly emergency C-section.
• Increased clotting tendency of pregnancy.
• Older maternal age.
• Pre-existing hypertension, diabetes or heart disease.
• Smoking.
• Recent infection (postpartum endometritis, mastitis).
Special considerations
• Thrombolysis can be given in pregnancy but the decision is individualised — risks to mother and baby weighed against the stroke benefit.
• CT scans in pregnancy use shielding to minimise fetal radiation.
• Some stroke medications (warfarin, ACE inhibitors, ARBs, statins) need to be stopped or changed in pregnancy or breastfeeding.
• Future pregnancies after a stroke need careful planning with both stroke and obstetric specialists.
F.A.S.T. in pregnancy
Stroke signs in a pregnant or recently delivered woman are an emergency just as in anyone else. Don't assume the symptoms are pregnancy-related. Call 10177.
Particular warning signs in the postpartum period: severe headache that doesn't resolve, vision changes, sudden weakness, severe pain in the upper abdomen (could be HELLP syndrome).
Stroke and HIV
HIV is a risk factor for stroke independent of the standard risks — partly through chronic inflammation and accelerated atherosclerosis, partly through direct viral effects on blood vessels (HIV vasculopathy), and partly through opportunistic infections (TB meningitis, cryptococcal meningitis) that damage arteries at the base of the brain.
The numbers
• Untreated HIV roughly doubles stroke risk in adults.
• Effective antiretroviral treatment (ART) brings most of this risk back down close to baseline.
• Some older ART drugs raised cholesterol; modern regimens have less of this problem.
What to do
• Stay virally suppressed. This is the single biggest stroke-prevention move for HIV-positive South Africans.
• Add lipid panels and BP checks to your routine HIV clinic visits.
• Treat any standard risk factors aggressively — high BP, cholesterol, diabetes, smoking.
• If you have HIV and have a stroke, the workup will usually include extra investigations for opportunistic infections.
Atrial fibrillation (AFib) in detail
AFib is one of the most common causes of stroke in South Africans over 65. It is also one of the most preventable.
How to recognise AFib
Often nothing — about half of patients have no symptoms. When symptoms occur:
• Heart palpitations — racing, fluttering, or skipping beats.
• Shortness of breath, especially on activity.
• Fatigue out of proportion to effort.
• Light-headedness or dizziness.
• Chest discomfort.
How AFib is diagnosed
• An irregular pulse on examination (anyone can check this — count your pulse for 30 seconds and watch the rhythm).
• An ECG confirms it.
• Sometimes a 24 — 48 hour Holter monitor catches paroxysmal (intermittent) AFib.
• Some smartwatches and home BP monitors with AFib detection are now reasonably good.
Treatment after AFib-related stroke
Anticoagulation (warfarin or a DOAC — article 10) is the cornerstone. Plus rate control medications (beta-blockers, calcium channel blockers) to slow the heart, and sometimes rhythm control attempts (electrical cardioversion, ablation).
The CHA₂DS₂-VASc score
Your clinic will use this to decide whether to anticoagulate. It scores your stroke risk based on heart failure, hypertension, age, diabetes, prior stroke, vascular disease, sex. A score of 2 or more generally means anticoagulation is recommended.
Stroke in sickle cell disease
Sickle cell disease (SCD) causes red blood cells to take on an abnormal shape that blocks small arteries. Brain arteries are particularly vulnerable. Stroke is one of the most serious complications, particularly in children.
The picture in children
• Risk of overt stroke by age 20 is about 11% in children with HbSS without preventive treatment.
• “Silent strokes” — small areas of brain damage with no obvious symptoms — affect another 20 – 35% by age 18.
• Both can cause long-term cognitive problems if not prevented.
Prevention
• Transcranial Doppler ultrasound — annual screening of brain artery velocity from age 2. High-velocity readings predict stroke risk.
• Chronic blood transfusions — for children with high-velocity readings. Reduces stroke risk by 90%.
• Hydroxyurea — a long-term medication that reduces sickling and reduces stroke risk.
• Bone marrow transplant — curative in selected patients with a matched donor.
SCD is uncommon in South Africa overall but found in some communities of African and Mediterranean ancestry. Children identified in infancy are usually followed by a paediatric haematologist.
Stroke and the combined oral contraceptive pill
The combined pill (oestrogen + progestogen) roughly doubles stroke risk in women under 35. The absolute risk is still small (about 1 in 5 000 per year) but the relative increase is significant — particularly when combined with:
• Smoking.
• High BP.
• Migraine with aura.
• Family history of clotting disorders.
• Age over 35.
After a stroke, the combined pill is generally stopped permanently. Alternatives include progestogen-only pills, intrauterine devices, implants, and (in older women) considered hormone replacement therapy is sometimes safe. The choice depends on the patient's full picture.
Stroke from illicit drugs
Cocaine, methamphetamine (“tik”), and amphetamines can cause acute stroke through sudden BP spikes, artery spasm, and triggering of underlying aneurysms. Stroke can occur within minutes to hours of use, and in patients with no other risk factors.
If you or someone you know is struggling with stimulant use, support is available through SANCA (011 892 3829), public-sector addiction clinics, and Narcotics Anonymous.
Inherited clotting disorders
Several genetic conditions increase clotting tendency:
• Factor V Leiden mutation.
• Prothrombin gene mutation.
• Protein C, Protein S, and Antithrombin deficiencies.
• Antiphospholipid syndrome (acquired, not strictly inherited).
These are usually tested for in young stroke patients without other obvious causes. Treatment may involve long-term anticoagulation.
The bigger picture
Stroke in special cases is medicine at its most personalised. Each patient's investigation map is different. Each treatment plan is different. The general principles from articles 4, 8, 9 and 10 still apply — manage BP, manage cholesterol, manage blood sugar, walk, eat well, don't smoke, take medication. But the special-case specifics need a stroke specialist's involvement, sometimes a cardiologist, sometimes a haematologist, sometimes an obstetrician.
If you are reading this because you (or someone you love) is a young stroke patient or has an unusual cause, ask for a specialist referral. Most SA stroke specialists are happy to take referrals from public clinics; many of them work in both public and private settings. The Heart and Stroke Foundation can sometimes help with referral guidance.
The final article in the series steps back from any single intervention and takes the long view — what life after stroke can look like over years and decades, the four anchors of staying well, and a reading list back to all 12 articles.
Where to get more help
Heart and Stroke Foundation South Africa — heartfoundation.co.za · 021 422 1586 — including young-stroke and survivor support.
Sickle Cell Disease Association of South Africa — patient and family information.
SANCA — 011 892 3829 — substance use support.
Phila Today High Blood Pressure Series Article 11 — pregnancy and pre-eclampsia in detail.
Phila Today Stroke Series — next, and final: living well after stroke — the long view.
Phila Today · Article 11 of 12 in the Stroke Series