| Background and purpose: Ischemic stroke in young adults accounts for about 10% of all ischemic strokes. It is relatively a rare subtype as compared with the ischemic stroke in the elderly. However, the young patients who suffer a stroke may live with their disability longer than the older patients, and are thus subject to a lifetime of medical complications which determine high socioeconomic costs. The etiologic spectrums in young patients are more diverse than in older patients. This paper aims to investigate the etiology of ischemic stroke with intracranial or extracranial arteries moderate or high-grade stenosis in young adults, which have been demonstrated by conventional angiography, and to explore the relationship between various therapies including medical therapy, endovascular intervention and vascular surgery, and end-point events, including the recurrence of stroke and death. As we know that no similar research report has been published in China.Subjects and methods: In this case series we retrospectively evaluated 141 young stroke patients (41 females and 100 males, average age is 38.7 years old [SD 5.2] )admitted to Xuanwu Hospital, the Capital University of Medical Sciences from November 2000 to December 2005. The patients with intracranial or extracranial arteries moderate or high-grade stenosis were demonstrated by conventional angiography. A total of 100 patients (70.9%) were diagnosed as cerebral infarction and 41 (29.1%) were diagnosed as transient ischemic attack in clinical practice. The medical history (including myocardial infarction, cerebral infarction, and hypertension), personal history (including smoking, and alcoholic consumption) and the family history of angiopathy of all patients were collected. Their serum triacylglycerol (TG), total cholesterol (TC), high-density lipoprotein cholesterol (HDL), low density lipoprotein cholesterol (LDL), apolipoprotein A1 (ApoA1), apolipoprotein B (ApoB), hematocrit (Hct), fibrinogen (Fib) and homocysteic acid (Hcy) were measured. The conventional angiography for aortic arch and four-vessel cerebral arteries was performed during the hospital stay. Eighty-three patients with intracranial or extracranial arteries moderate or high-grade stenosis were treated with selected medicine (aspirin etc.), 46 were treated with endovascular intervention (stent placement or balloon dilation angioplasty alone), and 12 were treated with vascular surgery (extracranial-intracranial bypass) according to their vascular conditions and will. Oral aspirin and end-point events were followed-up by telephone. Statistical analyses were performed by using SPSS 13.0 for Windows. The mono-factor chi-squared test and multi-factor logistic regression analyses were used to investigate the etiology of the patients and the effects of various therapies on the end-point events in the study.Results: Sixty-nine patients were followed, and the mean follow-up period was 35 months (SD 19). The recurrence of stroke occurred in seven patients, and three died. The incidence of end-point event was 14.5%. The distribution of risk factors was as following: hypertension 41 patients (29.1%), diabetes 11(7.8%), coronary heart disease 7 (5.0%), family history of vascular disease 27(19.1%), smoking 70/124 (56.5%), and history of alcoholic consumption 33/117 (28.2%). Laboratory examinations: the increased levels of TG (abnormal rate 95.0%), low levels of HDL (abnormal rate 43.1%) and increased levels of Hcy (abnormal rate 37.9%) were predominant. The angiographic findings demonstrated that there were 19.1% patients with moderate- or high-grade stenosis in extracranial anterior circulation arterires, and 16.3% in extracranial posterior circulation arteries. Taken them together, moderate- or high-grade stenosis in extracranial arteries was 28.4%. there was 76.6% and 14.2% of patients having moderate- or high-grade stenosis in intracranial anterior circulation arteries and intracranial posterior circulation arteries, respectively. In overall,, moderate- or high-grade stenosis in extracranial arteries was 84.4%. The rate of intracranial arteries moderate- or high-grade stenosis were significantly higher than extracranial arteries (P=0.000). The rate of anterior circulation arteries moderate- or high-grade stenosis were higher than posterior circulation arteries, especially intracranial anterior circulation arteries were significantly higher than intracranial posterior circulation arteries (P=0.000). Eight patients (9.6%) had end-point events in the medical treatment group, 1 (2.2%) in the endovascular treatment group, and 1 (8.3%) in the vascular surgery group. There were no significant differences among those three groups (P = 0.282); however, there was a trend suggesting that the endovascular treatment group was superior to the other two groups. Multi-factors logistic regression analysis showed that hypertension (OR 5.502, 95% CI 1.152-26.263), Fib (OR 10.773, 95%CI 1.241-93.508), and treatment manner (OR 0.206, 95%CI 0.038-1.108) were significant factors.Conclusions: Firstly, among young ischemic stroke patients with intracranial or extracranial arteries moderate- or high-grade stenosis, the incidence of conventional risk factors was not high, but smoking, hyperlipoidemia (especially increased TG) and hyperhomocysteinemia were the important factors to be concerned. Secondly, the number of young stroke patients with intracranial arteries moderate- or high-grade stenosis detected by DSA (especially in middle cerebral artery M1 segment) was much higher than that of the patients with extracranial arteries; and the incidence of moderate- or high-grade stenosis in anterior circulation arteries were higher than that in the posterior circulation arteries, especially in intracranial arteries. Thirdly, the long-term prognosis of ischemic stroke patients in young adults was better; the stroke recurrence and death is less likely. Lastly, no significant influence was detected on the end-point events when young ischemic stroke patients with intracranial or extracranial arteries moderate- or high-grade stenosis were treated by medications (aspirine etc.), endovascular stenting or vascular surgery (intracranial-extracranial bypass). And there was no significant difference among three groups; however, it was suggested that endovascular therapy was superior to others. Consequently, endovascular intervention was an aggressive choice in young ischemic stroke patients with intracranial or extracranial arteries moderate- or high-grade stenosis. The patients, who have interventional contraindications or difficulties to operate, may select extracranial-intracranial-artery bypass. However, whether using the endovascular intervention or vascular surgery, adequate antiplatelet and lipid lowering treatment are necessary before or after operation.
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