Rapidly progressive stroke in a young adult with very low high-density lipoprotein cholesterol

Ischemic strokes can affect young adults (15-45 years old). Most such strokes are caused by cardioembolic events, small vessel disease, or illicit drug use, and less frequently by large vessel atherosclerosis. Large vessel cerebral atherosclerosis is usually associated with high levels of low-density lipoprotein (LDL) cholesterol, but a low level of high-density lipoprotein (HDL) is also a risk factor for ischemic strokes. The magnitude of increased risk is unclear, particularly with extremely low HDL levels found only in various genetic and inherited disorders. Advanced atherosclerosis developed in the patient in this study, with HDL of 3 mg/dL, leading to rapidly progressive stroke with a fatal outcome. The disease primarily affected the posterior circulation. The course of this case illustrates that very low HDL may be associated with advanced cerebrovascular atherosclerosis and fatal stroke, and as such should be considered in young individuals with stroke.