Cerebral infarction in patients aged 16 to 35 years. Prospective study of 52 cases

OBJECTIVES: Aetiologies of cerebral ischemic events in young adults are various and often contraversial: atherosclerosis plays a role after age 35 years, cardioembolism is often recognized as the major cause, and numerous new predisposing conditions have been described. To evaluate very premature cerebral infarction, we studied prospectively 52 consecutive patients (34 women and 18 men) aged 16-35 years (mean 28.6 +/- 5.6 years) admitted over a 6-year period for an arterial cerebral infarct identified on CT, on MRI or both. METHODS: All patients were investigated using a standard protocol including cerebral angiography, transthoracic echocardiography, 24-hour Holter ECG monitoring, coagulation inhibitors levels, lupus anticoagulant testing, HIV and syphilitic serologies. Additional investigations were performed in a majority of patients: transesophageal echocardiography in 33, contrast echocardiography in 50, and anticardiolipin antibodies levels in 38. RESULTS: The arterial distribution of infarction did not differ from that of overall stroke patients. Sixteen cases were classified as certain aetiologies, including cardiac diseases with high embolic risk (n = 9), spontaneous arterial dissection (n = 4), moya-moya disease (n = 1), atherosclerosis (n = 1), and inherited antithrombine III deficiency (n = 1). Eighteen cases were classified as possible aetiologies including cardiac diseases with low embolic risk (n = 11) such as mitral valve prolapse or atrial septal aneurysm, miscellaneaous arteriopathies (n = 3) such as arterial dysplasia, antiphospholipid antibodies syndrome (n = 1) and migrainous stroke (n = 3). The 18 last cases were classified as unknown aetiologies, despite all patients but one had at least one vascular risk factor: this group significantly differed from the formers in that the patients were more frequently women using oral contraceptive associated with tobacco consumption, hypercholesterolemia, or both. Two patients died acutely and the survivors were followed 31 +/- 18 months. Three patients experienced recurrent stroke. Functional outcome was assessed using the Rankin scale on admission and 6 to 12 months after the onset of stroke: patients evaluated < or = 2 (no to mild handicap) were 31% on admission and 82% after recovery. Twenty six p. cent remained unable to resume a work. CONCLUSION: Despite extensive evaluation, identification and classification of aetiologies of cerebral infarction in young adults should be cautious because the risk as well as the pathogenesis of many potential causes still need to be defined.