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Background: The diagnostic value of cerebrospinal fluid (CSF) analysis in identification of stroke etiology in patients with juvenile stroke remains not well studied. We sought to determine the frequency and underlying causes of pathological CSF-findings in juvenile stroke patients who underwent CSF-analysis as part of their diagnostic work-up.Methods: We retrospectively abstracted data from consecutive (01/2008 to 12/2015) patients aged 18 to 45 years with acute ischemic stroke or transient ischemic attack. Routine work-up included MRI with dissection-sensitive sequences, Holter-ECG, transthoracic and transesophageal echocardiography, duplex ultrasound of extra- and intracranial arteries and screening for coagulopathies, vasculitis and Fabry disease. CSF-analysis was routinely performed in patients with hitherto cryptogenic stroke. We assessed frequency and causes of pathological CSF-findings including microbiological and virological abnormalities, and their impact on the choice of specific therapy for secondary stroke prevention.Results: Among 379 juvenile patients with acute ischemic stroke or transient ischemic attack, CSF analysis was performed in 201 patients (53%). Of these, 26 patients (13%) had CSF pleocytosis (leucocyte cell count ≥5 Mpt/l). CSF-pleocytosis was rated false positive (e.g. traumatic lumbar puncture, reactive pleocytosis due to acute stroke) after exclusion of specific conditions in 23 of these patients. Only 2 patients with CSF-pleocytosis (1% of patients who underwent CSF analysis) had specific CSF-findings (Lyme disease and neurosyphilis with consecutive cerebral vasculitis) as a cause of stroke and subsequent impact on secondary stroke prevention therapy. One patient had serological evidence of chronic infection with Mycoplasma pneumoniae that was rated as a contributing factor to stroke pathophysiology.Conclusions: The diagnostic yield of routine CSF-analysis in juvenile stroke patients was remarkably low in our study. Our data suggest that CSF-analysis should only be performed if further findings raise the suspicion of cerebral vasculitis.