Young-onset stroke in the UAE: A single-centre retrospective analysis of risk factors and outcomes

Clinical Question (PICO)

Population: Adults younger than 50 years admitted with stroke to Al Qassimi Hospital in Sharjah, United Arab Emirates, from 2016 through 2022. Exposure/comparison: Demographic characteristics, vascular comorbidities, stroke subtype, diagnostic classification, and acute management, with comparisons by stroke type, sex, and South Asian versus non–South Asian origin. Outcomes: Distribution of ischemic, intracerebral hemorrhage, and non-traumatic subarachnoid hemorrhage; identified risk factors and etiologies; use of thrombolysis and endovascular treatment; and in-hospital mortality. Prespecified subgroups: Stroke subtype, sex, diabetes status, and region of origin as defined in the study analyses.

Bottom Line

In this single-centre retrospective cohort of 419 young adults with stroke, hypertension affected 45.45% and diabetes 24.42%; ischemic stroke accounted for 50.12%, but 46.19% of ischemic strokes were classified as of undetermined etiology. Acute reperfusion access was limited—19.79% of ischemic patients received intravenous thrombolysis and only 1 patient underwent mechanical thrombectomy—and overall in-hospital mortality was 12.68%.

Design

Trial type: Retrospective, single-centre chart review; observational, not randomized or blinded.
N: 419 included patients younger than 50 years.
- Ischemic stroke: 210 (50.12%)
- Intracerebral hemorrhage: 114 (27.21%)
- Non-traumatic subarachnoid hemorrhage: 95 (22.67%)
Randomization: None; comparisons were observational and unadjusted in the reported associations.
Setting: Al Qassimi Hospital, Sharjah, UAE.
Enrollment: 2016–2022 admissions; 537 records were initially extracted, with duplicate records and cases with more than 50% missing data excluded.
Mean follow-up: No longitudinal follow-up; outcomes were principally during the index hospitalization.
Analysis: Descriptive analysis and statistical comparisons using Python-based statistical libraries; the report gives odds-ratio-style comparisons with 95% CIs and P values for selected subgroup associations.
Primary outcome: The epidemiological and clinical profile of young-onset stroke, including risk factors, stroke subtype, management, and in-hospital outcome.

Population

Inclusion Criteria

Age below 50 years.
Admission to Al Qassimi Hospital between 2016 and 2022 with a diagnosis of ischemic stroke, intracerebral hemorrhage, or non-traumatic subarachnoid hemorrhage.

Exclusion Criteria

Duplicate records, defined by redundant Encounter ID and admission date.
Cases with more than 50% missing data.

Baseline Characteristics (overall cohort)

Mean age: 39.99 ± 7.24 years.
Male sex: 328/419 (78.28%); female sex: 91/419 (21.72%).
Region of origin: South Asia 268/419 (63.96%), MENA 81/419 (19.33%), other regions 47/419 (11.22%), and Sub-Saharan Africa 23/419 (5.49%).
Mean BMI: 27.26 ± 5.01 kg/m².
Mean admission blood pressure: 156.80 ± 35.13 mmHg systolic and 93.60 ± 22.54 mmHg diastolic.
Hypertension: 175/385 (45.45%); diabetes mellitus: 94/385 (24.42%); coronary artery disease: 27/378 (7.14%).

Interventions

Diagnostic and medical care: Care was delivered as recorded in routine practice; the study did not impose a treatment protocol. Inpatient telemetry and transthoracic echocardiography were used, while prolonged outpatient rhythm monitoring and transoesophageal echocardiography with bubble or contrast studies were not routinely used at the centre.
Intravenous thrombolysis: 37/393 (9.41%) of the overall cohort and 37/187 (19.79%) of documented ischemic-stroke patients received thrombolytic therapy.
Endovascular intervention: 2/409 (0.49%) underwent an endovascular intervention overall; 1/210 (0.48%) of ischemic-stroke patients underwent mechanical thrombectomy.
Other acute treatment: Aspirin was administered to 177/419 (42.24%).

Outcomes

Primary Outcome (epidemiological profile and in-hospital outcome):

Ischemic stroke was the most common subtype: 210/419 (50.12%); intracerebral hemorrhage accounted for 114/419 (27.21%), and non-traumatic subarachnoid hemorrhage for 95/419 (22.67%).
Among ischemic strokes, TOAST classification identified cardioembolism in 8/210 (3.81%), large-artery atherosclerosis in 52/210 (24.76%), small-vessel disease in 23/210 (10.95%), and undetermined etiology in 97/210 (46.19%).
The paper reports that the cause remained undetermined in approximately 46.78% of the total cohort (196/419), although the completeness of etiologic testing was limited.
South Asian patients were more likely than non–South Asian patients to have large-artery atherosclerosis: 26.70% versus 14.29%; reported odds ratio 2.19, 95% CI 1.11–4.30, P = 0.02. This is an observational association, not a causal ethnic effect.
Female patients were more likely than male patients to have hemorrhagic rather than ischemic stroke: reported odds ratio 2.23, 95% CI 1.37–3.65, P = 0.001.
Patients with ischemic stroke were more likely than those with hemorrhagic stroke to have diabetes mellitus: reported odds ratio 2.13, 95% CI 1.17–3.88, P = 0.014.
Hypertension was not significantly associated with hemorrhagic transformation within 24 hours (P = 0.38).
Hemorrhagic-stroke patients had higher in-hospital mortality than ischemic-stroke patients: reported odds ratio 3.41, 95% CI 1.73–6.69, P < 0.001.
Overall in-hospital mortality was 53/418 (12.68%): ischemic stroke 16/210 (7.62%), intracerebral hemorrhage 25/114 (21.93%), and subarachnoid hemorrhage 12/94 (12.77%). Coronary artery disease was significantly associated with death (P < 0.001), although the article does not present a fully adjusted mortality model in the abstracted results.

Secondary Outcomes:

South Asian patients comprised 63.96% of the cohort and had higher recorded rates of intravenous thrombolysis than non–South Asian patients: 13.31% versus 2.76%.
Large-artery atherosclerosis was recorded in 26.70% of South Asian versus 14.29% of non–South Asian ischemic-stroke patients; undetermined etiology remained common in both groups (48.51% versus 43.71%).
Hemorrhagic transformation within 24 hours occurred in 21/339 (6.19%) of patients with available data.
Atrial fibrillation was recorded in only 4/380 (1.05%), but the limited monitoring strategy makes this an underestimate plausible rather than a reassuring exclusion.

Adverse Events / Safety:

This was not a treatment-safety trial and did not establish comparative safety of thrombolysis or thrombectomy.
Reported hemorrhagic transformation within 24 hours was 6.19% among patients with available data.
Mortality was 12.68% overall, with the highest observed rate in intracerebral hemorrhage (21.93%).

Figures

*Figure 1.* Patient selection flowchart.

Criticisms

Single-centre selection: The cohort reflects one tertiary hospital in Sharjah and cannot establish UAE-wide incidence, treatment access, or mortality.
Retrospective missingness: 118 of 537 extracted records were excluded because of duplication or more than 50% missing data; the direction of resulting selection bias is unknown.
Etiologic under-investigation: Approximately 46% of ischemic strokes were labeled undetermined, while prolonged rhythm monitoring, implantable loop recorders, and routine transoesophageal or bubble echocardiography were not consistently available.
Confounding by social structure: Region of origin is entangled with sex, occupation, insurance coverage, migration status, health-seeking behavior, and access to care; the South Asian association with large-artery atherosclerosis should not be read as a biologic causal effect.
Small intervention counts: Only 1 ischemic patient underwent mechanical thrombectomy, so the study cannot estimate treatment effectiveness or explain how many patients were eligible but untreated.
Outcome scope: Mortality was primarily in-hospital, with no systematic long-term functional outcome, recurrent stroke, or return-to-work assessment.
No causal model: The observational associations and P values do not show that hypertension, diabetes, origin, or treatment access caused the observed outcomes.

Funding

The authors reported that they received no specific funding for this work. No trial registration was reported.

The paper

Authors. Sobia Siddiq et al.
Title. Young-onset stroke in the UAE: A single-centre retrospective analysis of risk factors and outcomes.
Journal. PLOS One.
Year. 2026.
DOI. 10.1371/journal.pone.0355300
PMCID. PMC13446658

Deep Dive — click to expand

What this is

This is not a trial of a young-stroke treatment. It is a 419-patient snapshot from one UAE hospital showing that stroke before age 50 is often a conventional vascular-risk problem, not a disease of otherwise healthy young people: 45.45% had hypertension and 24.42% had diabetes. The sharper operational finding is the mismatch between burden and system response: among ischemic strokes, 46.19% remained etiologically undetermined, only 19.79% received intravenous thrombolysis, and only one patient underwent mechanical thrombectomy. The 12.68% in-hospital mortality is a signal for prevention and systems-of-care work, not a causal estimate of what any single intervention would achieve.

1. Shadow Audit

The headline “young-onset stroke is driven by hypertension and diabetes” is directionally credible but incomplete. The cohort also contained a large diagnostic blind spot: 196 of 419 patients (46.78%) had an undetermined cause overall, and 97 of 210 ischemic strokes (46.19%) were undetermined by the reported TOAST classification. The authors themselves note that inpatient telemetry and transthoracic echocardiography were not supplemented routinely by prolonged rhythm monitoring, implantable loop recorders, or transoesophageal/bubble echocardiography. The apparent atrial-fibrillation rate of 1.05% is therefore a measurement result under limited surveillance, not proof that occult AF is rare. A second hidden finding is the access problem: 0.24% of the overall cohort received mechanical thrombectomy despite the hospital’s high-income setting, and the paper attributes this to the absence of a dedicated 24/7 neuro-interventional service and reliance on one interventional radiologist.

2. Inversion Engine

For the conclusion to invert from “prevention and access need strengthening” to “this is mainly an unusual, non-modifiable young-stroke population,” the missing etiologic and access data would have to explain a large share of the cohort. A concrete inversion threshold would be reclassifying at least half of the 196 undetermined cases—roughly 98 patients—as aetiologies not addressed by blood-pressure and diabetes prevention, such as cardioembolism, dissection, thrombophilia, or structural cardiac disease. That would materially weaken the metabolic-prevention framing, but this study did not perform the work-up needed to test it. Conversely, the treatment-access conclusion would weaken if a registry audit showed that almost all of the 210 ischemic cases were ineligible for reperfusion; the current paper does not provide the imaging, onset-time, or eligibility denominators needed to distinguish ineligibility from under-delivery.

3. Second-Order Catalyst

The first group that should move is the tertiary stroke service, not the public-health ministry waiting for another prevalence estimate. A young-stroke pathway can be changed rapidly: flag patients under 50 for a structured vascular-risk review; document last-known-well and vascular imaging; ensure rapid transfer or 24/7 interventional coverage for eligible large-vessel occlusion; and reserve a defined etiologic follow-up pathway for prolonged rhythm monitoring and appropriate cardiac imaging when initial testing is unrevealing. The protocol should be tested across multiple UAE hospitals, with denominators for imaging-confirmed LVO, thrombolysis eligibility, thrombectomy eligibility, treatment times, and 90-day functional outcome. That would turn this paper’s system signal into an actionable quality-improvement program within months rather than years.

4. Asymmetric Leverage

The largest denominator is prevention: 175 of 385 patients with available data had hypertension and 94 of 385 had diabetes. A modest improvement in detection, control, and continuity across those groups could reach far more people than an intervention aimed at the tiny number of young patients with LVO. The highest per-patient leverage is acute access: one thrombectomy in 210 ischemic strokes is not an efficacy estimate, but it is a stark capacity marker. The rational portfolio is therefore two-speed—population-level hypertension and diabetes prevention for the broad burden, paired with 24/7 reperfusion and transfer capability for the smaller, high-severity subgroup where time-sensitive treatment can have a large individual payoff.

5. Paradigm Destroyer

This paper kills two reflexes: “young means low vascular risk” and “undetermined means fully investigated.” It also challenges the assumption that a high-income health system automatically provides high-value stroke access. A practical protocol update would read: For every patient under 50 with stroke, treat hypertension and diabetes as active causes until assessed, not as background history. If the initial etiologic evaluation is unrevealing, trigger a defined prolonged-rhythm and structural-cardiac work-up, while routing every suspected LVO through a verified 24/7 EVT pathway.

MVP — Minimum Viable Proof

The minimum proof that should change bedside and system practice is a multicentre UAE dataset reproducing three numbers with complete denominators: at least 40% of young-stroke patients have hypertension, at least 20% have diabetes, and more than 40% of ischemic cases remain undetermined after the current inpatient work-up. If that pattern holds and a standardized pathway improves etiologic yield or reperfusion access without increasing complications, young-stroke care should be redesigned around both aggressive vascular-risk control and deeper etiologic testing—not around the assumption that young patients are atypical and low risk.

Best Combination

Use this study as a needs-assessment signal, then combine it with established evidence for intensive hypertension and diabetes prevention, prolonged rhythm monitoring after cryptogenic stroke, and randomized thrombectomy and thrombolysis pathways. The combination is stronger than any component alone: this cohort identifies who is being missed and where the system is thin; the prevention and reperfusion literature supplies the interventions; and a prospective, multicentre registry can test whether the gap is modifiable. The immediate evidence-based synthesis is not “all young strokes need the same work-up,” but “young age should not reduce urgency, and an undetermined label should reflect completed testing rather than limited access.”

Overvalue Warning

Do not interpret the 2.19 association between South Asian origin and large-artery atherosclerosis as a biologic or ethnic causal effect; origin is entangled with occupation, insurance, migration, and healthcare access in this cohort.
Do not treat the 12.68% mortality rate as a national benchmark or as proof that low thrombectomy use caused excess deaths. It is an in-hospital estimate from one selected hospital with substantial missingness, mixed stroke subtypes, and no adjusted causal comparison.

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