Background: Leading aetiologies of ischaemic stroke in young adults are cervico-cerebral arterial dissections and cardio-embolism, but the causes remain undetermined in a considerable proportion of cases. In a few reports, intracranial arterial stenosis has been suggested to be a potential cause of ischaemic stroke in young adults. The aim of our work was to evaluate the frequency, characteristics and risk factors of intracranial arterial stenosis in a prospective series of young ischaemic stroke patients. Methods: The study was based on a prospective consecutive hospital-based series of 159 patients aged 18-45 years who were admitted to our unit for an acute ischaemic stroke from October 2005 to December 2010. A structured questionnaire was used in order to assess common vascular risk factors such as hypertension, diabetes, hypercholesterolemia, use of tobacco, alcohol and illicit drugs, migraine, and, in women, oral contraceptive use. A systematic screening was performed, including the following: brain magnetic resonance imaging or, if not feasible, brain computed tomography scan, carotid and vertebral Duplex scanning and trans-cranial Doppler sonography, 3D time-of-flight magnetic resonance cerebral angiography or cerebral computed tomography angiography. Long-duration electrocardiography, trans-thoracic and trans-oesophageal echocardiography were performed and laboratory blood investigations were extensive. Urine samples were screened for cannabinoids, cocaine, amphetamine and methylene-dioxy-methamphetamine. When this initial work-up was inconclusive, trans-femoral intra-arterial selective digital subtraction angiography with reconstructed 3D images was performed. Results: In this series, 49 patients (31%) had intracranial arterial stenosis. Other defined causes were found in 91 patients (57%), including cardio-embolism in 32 (20%), cervical dissection in 23 (14%), extracranial atherosclerosis in 7 (4%), haematological disorders in 7 (4%), small vessel disease in 1, and isolated patent foramen ovale in 21 (13%); in 19 patients (12%), ischaemic stroke was related to an undetermined aetiology. Comparing risk factors between patients with intracranial arterial stenosis and those with other definite causes showed that there were only two significant differences: a lower age and a higher frequency of vasoactive substances (especially cannabis) in patients with intracranial arterial stenosis. All intracranial arterial stenosis in patients who used vasoactive substances were located in several intracranial vessels. Conclusions: Intracranial arterial stenosis may be an important mechanism of stroke in young patients and it should be systematically investigated using vascular imaging. Strong questioning about illicit drug consumption (including cannabis) or vasoactive medication use should also be performed. It should be emphasized for health prevention in young adults that cannabis use might be associated with critical consequences such as stroke.

Arnold M, Halpern M, Meier N, Fischer U, Haefeli T, Kappeler L, Brekenfeld C, Mattle HP, Nedeltchev K: Age-dependent differences in demographics, risk factors, co-morbidity, etiology, management, and clinical outcome of acute ischemic stroke. J Neurol 2008;255:1503-1507.
Varona JF, Bermejo F, Guerra JM, Molina JA: Long-term prognosis of ischemic stroke in young adults. Study of 272 cases. J Neurol 2004;251:1507-1514.
Chatzikonstantinou A, Wolf M, Hennerici MG: Ischemic stroke in young adults: classification and risk factors. J Neurol 2012;259:653-659.
Yamamoto F: Ischemic stroke in young adults: an overview of etiological aspects. Arq Neuropsiquiatr 2012;70:462-466.
Janssen AW, de Leeuw FE, Janssen MC: Risk factors for ischemic stroke and transient ischemic attack in patients under age 50. J Thromb Thrombolysis 2011;31:85-91.
Lee TH, Hsu WC, Chen CJ, Chen ST: Etiologic study of young ischemic stroke in Taiwan. Stroke 2002;33:1950-1955.
Balci K, Utku U, Asil T, Celik Y: Ischemic stroke in young adults: risk factors, subtypes, and prognosis. Neurologist 2011;17:16-20.
Leys D, Bandu L, Henon H, Lucas C, Mounier-Vehier F, Rondepierre P, Godefroy O: Clinical outcome in 287 consecutive young adults (15 to 45 years) with ischemic stroke. Neurology 2002;59:26-33.
Rasura M, Spalloni A, Ferrari M, De Castro S, Patella R, Lisi F, Beccia M: A case series of young stroke in Rome. Eur J Neurol 2006;13:146-152.
Nedeltchev K, der Maur TA, Georgiadis D, Arnold M, Caso V, Mattle HP, Schroth G, Remonda L, Sturzenegger M, Fischer U, Baumgartner RW: Ischaemic stroke in young adults: predictors of outcome and recurrence. J Neurol Neurosurg Psychiatry 2005;76:191-195.
Musolino R, La Spina P, Granata A, Gallitto G, Leggiadro N, Carerj S, Manganaro A, Tripodi F, Epifanio A, Gangemi S, Di Perri R: Ischaemic stroke in young people: a prospective and long-term follow-up. Cerebrovasc Dis 2003;15:121-128.
Ji R, Schwamm LH, Pervez MA, Singhal AB: Ischemic stroke and transient ischemic attack in young patients. JAMA Neurol 2013;70:51-57.
Tancredi L, Boneschi FM, Braga M, Santilli I, Scaccabarozzi C, Lattuada PQ, Sessa M, Fumagalli L, Iurlaro S, Neromante I, De Lodovici ML, Roccatagliata DV, Giacalone G, Arnaboldi M, Crespi V, Agostoni E, Comi GC, Ferrarese C, Sterzi R: Stroke care in young patients. Stroke Res Treat 2013;2013:715380.
Ferro JM, Massaro AR, Mas JL: Aetiological diagnosis of ischaemic stroke in young adults. Lancet Neurol 2010;9:1085-1096.
Phillips MC, Leyden JM, Chong WK, Kleinig T, Czapran P, Lee A, Koblar SA, Jannes J: Ischaemic stroke among young people aged 15 to 50 years in Adelaide, South Australia. Med J Aust 2011;195:610-614.
Putaala J, Metso AJ, Metso TM, Konkola N, Kraemer Y, Haapaniemi E, Kaste M, Tatlisumak T: Analysis of 1,008 consecutive patients aged 15 to 49 with first-ever ischemic stroke. The Helsinki Young Stroke registry. Stroke 2009;40:1195-2203.
Cerrato P, Grasso M, Imperiale D, Priano L, Baima C, Giraudo M, Rizzuto A, Azzaro C, Lentini A, Bergamasco B: Stroke in young patients: etiopathogenesis and risk factors in different age classes. Cerebrovasc Dis 2004;18:154-159.
Amarenco P, Bogousslavsky J, Caplan LR, Donnan GA, Wolf ME, Hennerici MG: The ASCOD phenotyping of ischemic stroke (updated ASCO phenotyping). Cerebrovasc Dis 2013;36:1-5.
Fromm A, Waje-Andreassen U, Thomassen L, Naess H: Comparison between ischemic stroke patients <50 years and ≥50 years admitted to a single centre: the Bergen Stroke Study. Stroke Res Treat 2011;2011:183256.
Yao XY, Lin J, Geng JL, Sun YM, Chen Y, Shi GW, Xu Q, Li YS: Age- and gender-specific prevalence of risk factors in patients with first-ever ischemic stroke in China. Stroke Res Treat 2012;2012:136398.
Barbieux M, Veran O, Detante O: Accidents vasculaires cérébraux ischémiques du sujet jeune et toxiques. Rev Med Interne 2012;33:35-40.
Westover AN, Mc Bride S, Haley RW: Stroke in young adults who abuse amphetamines or cocaine: a population-based study of hospitalized patients. Arch Gen Psychiatry 2007;64:495-502.
Wolff V, Armspach JP, Lauer V, Rouyer O, Bataillard M, Marescaux C, Geny B: Cannabis-related stroke: myth or reality? Stroke 2013;44:558-563.
Spengos K, Vemmos K: Risk factors, etiology, and outcome of first-ever ischemic stroke in young adults aged 15 to 45 - the Athens young stroke registry. Eur J Neurol 2010;17:1358-1364.
Martinez-Sanchez P, Fuentes B, Fernandez-Dominguez J, Ortega-Casarrubios Mde L, Aguilar-Amar MJ, Abenza-Abildua MJ, Idrovo-Freire L, Diez-Tejedor E: Young women have poorer outcomes than men after stroke. Cerebrovasc Dis 2011;31:455-463.
Bulder MM, Braun KP, Leeuwis JW, Lo RT, van Nieuwenhuizen O, Kapelle LJ, Klijn CJ: The course of unilateral intracranial arteriopathy in young adults with arterial ischemic stroke. Stroke 2012;43:1890-1896.
Rouanet F, Sibon I, Goizet C, Renou P, Meissner W; Groupe de travail de la SFNV: Etiological assessment of cerebral infarct in the young. Proposals from the working group of the French Neurovascular Society (December 2008). Rev Neurol (Paris) 2009;165:283-288.
Carvalho M, Oliveira A, Azevedo E, Bastos-Leite AJ: Intracranial arterial stenosis. J Stroke Cerebrovasc Dis 2014;23:599-609.
Prabhakaran S, Romano JG: Current diagnosis and management of symptomatic intracranial atherosclerotic disease. Curr Opin Neurol 2012;25:18-26.
Gonzalez NR, Liebeskind DS, Dusick JR, Mayor F, Saver J: Intracranial arterial stenoses: current viewpoints, novel approaches, and surgical perspectives. Neurosurg Rev 2012;36:175-184.
Beck F, Guilbert P, Gautier A: Cannabis, cocaine, ecstasy: entre experimentation et usage régulier. Baromètre Santé 2005. Attitudes et comportement de santé. Saint-Denis, INPES, 2007, pp 169-228.
Beck F, Guignard R, Richard JB, Léon C: Cannabis; in Atlas des usages de substances psychoactives 2010. Analyses régionales du Baromètre Santé de l'INPES. Etudes santé territoires. Saint-Denis, INPES, 2013, pp 28-29.
Desbois AC, Cacoub P: Cannabis-associated arterial disease. Ann Vasc Surg 2013;27:996-1005.
Wolff V, Rouyer O, Geny B: Response to letter regarding article, ‘cannabis-related stroke: myth or reality?' Stroke 2013;44:e57.
Wolff V, Lauer V, Rouyer O, Sellal F, Meyer N, Raul JS, Sabourdy C, Boujan F, Jahn C, Beaujeux R, Marescaux C: Cannabis use, ischemic stroke, and multifocal intracranial vasoconstriction. A prospective study in 48 consecutive young patients. Stroke 2011;42:1778-1780.
Fonseca AC, Ferro JM: Drug abuse and stroke. Curr Neurol Neurosci Rep 2013;13:325.
Barber PA, Pridmore HM, Krishnamurthy V, Roberts S, Spriggs DA, Carter KN, Anderson NE: Cannabis, ischemic stroke, and transient ischemic attack. A case-control study. Stroke 2013;44:2327-2329.
Ashton CH: Adverse effects of cannabis and cannabinoids. Br J Anaesth 1999;83:637-649.
O'Sullivan SE, Kendall DA, Randall D: Vascular effects of Δ9-tetrahydrocannabinol (THC), anandamide, and N-arachidonoyldopamine (NADA) in the rat isolated aorta. Eur J Pharmacol 2005;507:211-221.
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