Q: A young non-diabetic, non-smoker and non-alcoholic person has developed right hemiparesis. All his other investigations are within normal limits. He has internal carotid artery occluded. What is the further course of management and prognosis?

A:Stroke in the young suggests a thrombophilia, which is defined as an early thromboembolic episode (occurring before age 50 years), spontaneous thrombosis, recurrent thrombosis, unusual site of thrombosis, family history of thrombotic episodes, or coumarin-induced skin necrosis complications. Such patients may have an isolated or combined inherited deficiency in the proteins involved in coagulation. These may be inherited (genetic mutation such as factor V Leiden, protein C and S deficiencies, antithrombin and prothrombin 20210A mutations) or acquired such as auto immune disorders like SLE or antiphospholipid syndrome, paroxysmal nocturnal haemoglobinuria, hyperhomocysteinaemia, myeloproliferative disorders, chronic inflammatory disorders etc. Factors that predispose to thrombosis include: a) Age, previous thrombosis, smoking, b) Pregnancy, contraceptive therapy, hormone replacement therapy (HRT), c) Immobilisation: travel, bedfast, wheelchair, sedentary lifestyle, d) Diet, obesity (lipids) and immobilisation, e) Orthopaedic surgery, neurosurgery, trauma, fractures and f) Blood group non-O with increased VWF and VIII The diagnosis is confirmed by identification of an isolated or combined inherited coagulant deficiency. Factor V Leiden deficiency is the most common disorder and is found in 12-40% of white populations. Protein C and S deficiencies are more prevalent in Asian populations than in white. The following tests need to be done once the patient is off an anticoagulant such as warfarin or heparin and has taken no anticoagulant or has not had a thrombotic event for at least ten days: -Activated protein C resistance (APCR) -Lupus anticoagulant testing -Anticardiolipin antibodies IgG and IgM -Antithrombin activity -Fasting homocysteine -Factor VIII activity -Protein C & protein S activity -Prothrombin 20210 mutation assay In fact a patient needs work-up for thrombophilia when any of the following indications are present: 1. Venous thrombosis before 40-50 years of age 2. Unprovoked thrombosis at any age 3. Recurrent thromboses at any age 4. Unusual sites such as cerebral, mesenteric, portal, or hepatic veins 5. Positive family history for thrombosis 6. Thrombosis during pregnancy, oral contraceptives, or hormone replacement therapy (HRT) 7. Unexplained abnormal laboratory test such as prolonged PTT. They have a high risk of DVT and pulmonary embolism and standard anticoagulation protocols need to be followed once the diagnosis is established. The treatment varies, depending on the severity and circumstances of the blood clot and the choice of medication, dosage, and length of treatment will vary for each patient and their individual circumstances.