To determine the functional outcome in a cohort of young adults with ischemic stroke patients, focusing on components of lipid profile. In our registry including consecutive patients with first-ever ischemic stroke aged 15–49 from 1994 to 27, we analyzed predictors of 3-month functional outcome (modified Rankin Scale, mRS). Infarct size fell into small, medium, large posterior, or large anterior. Stroke severity was assessed with NIH Stroke Scale (NIHSS). Serum lipids were measured within 72 h after admission. Binary, multinomial ordinal, and Poisson regressions allowed revealing factors associated with size of infarct, stroke severity, and unfavorable outcome or death (mRS, 2–6) or mRS as an ordinal measure. In the 968 patients included (mean age, 41.3 ± 7.6; 62.6% men; 49.5% with mRS –1), factors associated with unfavorable outcome after multivariable analysis were increasing age (odds ratio, 1.3 per year; 95% confidence interval, 1.1–1.5), higher NIHSS score (1.23 per point, 1.17–1.29), large anterior (4.37, 2.26–8.42) or posterior (1.73, 1.5–2.85) infarcts, bilateral lesions (2.28, 1.3–3.98), internal carotid artery dissection (ICAD) (3.65, 1.41–9.47), and inversely high-density lipoprotein (HDL) levels (.58 per unit increase, .38–.86). Increasing HDL associated with smaller infarct size (.71, .51–.98). Both higher total and HDL cholesterol associated with lower NIHSS score (.96, .93–.98 for total cholesterol and .82, .75–.88 for HDL) and lower 3-month mRS (.87, .78–.97 for total cholesterol and .65, .47–.9 for HDL). In addition to known prognosticators, ICAD and lower HDL levels were independently associated with adverse clinical outcomes in our young adult stroke cohort.