Posterior versus Anterior Circulation Stroke in Young Adults: A Comparative Study of Stroke Aetiologies and Risk Factors in Stroke among Young Fabry Patients (sifap1)

Abstract

Background: Although 20-30% of all strokes occur in the posterior circulation, few studies have explored the characteristics of patients with strokes in the posterior compared to the anterior circulation so far. Especially data on young patients is missing. Methods: In this secondary analysis of data of the prospective multi-centre European sifap1 study that investigated stroke and transient ischemic attack (TIA) patients aged 18-55 years, we compared vascular risk factors, stroke aetiology, presence of white matter hyperintensities (WMH) and cerebral microbleeds (CMB) between patients with ischaemic posterior circulation stroke (PCS) and those having suffered from anterior circulation stroke (ACS) based on cerebral MRI. Results: We diagnosed PCS in 612 patients (29.1%, 407 men, 205 women) and ACS in 1,489 patients (70.9%). Their age (median 46 vs. 47 years, p = 0.205) and stroke severity (modified Rankin Scale: both 2, p = 0.375, Barthel Index 90 vs. 85, p = 0.412) were similar. PCS was found to be more frequent among the male gender (66.5 vs. 60.1% with ACS, p = 0.003). Vertebral artery (VA) dissection was more often the cause of PCS (16.8%) than was carotid artery dissection of ACS (7.9%, p < 0.001). Likewise, small vessel disease (Trial of Org 10172 in Acute Stroke Treatment [TOAST] = 3, PCS: 14.7%, ACS: 11.8%) and stroke of other determined aetiology (TOAST = 4, PCS: 24.5%, ACS: 16.0%) were more frequent in those with PCS. Furthermore, patent foramen ovale (PFO; PCS: 31.1%, ACS: 25.4%, p = 0.029) was more often detected in patients with PCS. In contrast, large-artery atherosclerosis (TOAST = 1, PCS: 15.4%, ACS: 22.2%) and cardio-embolic stroke (TOAST = 2, PCS: 15.6%, ACS: 18.0%) were less frequent in those with PCS (p < 0.001) as were preceding cerebrovascular events (10.1 vs. 14.1%, p = 0.014), TIA (4.8 vs. 7.7%, p = 0.016) and smoking (53.2 vs. 61.0%, p = 0.001). The presence, extent, and location of WMH and CMB did not differ between the 2 groups. Conclusions: Our data suggested a different pattern of aetiology and risk factors in young patients with PCS compared to those with ACS. These findings especially call for a higher awareness of VA dissection and potentially for more weight of a PFO as a risk factor in young patients with PCS. Clinical trial registration-URL: http://www.clinicaltrials.gov; NCT00414583.

Risk Factors and Clinical Manifestations of Juxtacortical Small Lesions: A Neuroimaging Study

“…This vulnerability of these regions may be related to the relatively poor blood supply of the anterior circulation. A recent study in young adults reported that large-artery atherosclerosis was more frequent in patients with anterior circulation stroke than in those with posterior circulation stroke ( 32 ), which was partly consistent with our result. Moreover, juxtacortical white matter, consists of U-fibers instead of long white matter tracts, is mostly supplied by short vessels at the boundary of white matter and cortex or the end of long penetrating medullary vessels, which would be easily influenced by atherosclerosis ( 3 , 33 ).…”

Predicting functional outcomes of posterior circulation acute ischemic stroke in first 36 h of stroke onset

“…The patients with acute medullary infarction were later confirmed as having vertebral artery dissection. In fact, vertebral artery dissection has been recognized as a frequent cause of posterior circulation stroke among young adults [ 13 , 24 ]. The PC-ASPECTS cannot be accurately assessed in medullary infarction.…”

Detailed phenotyping of posterior vs. anterior circulation ischemic stroke: a multi-center MRI study

“…However, male sex as risk factor for PCiS vs. ACiS has been reported previously [19][20][21]. A male preponderance in PCiS has been observed in both children [30] and young adults [5]. There are studies indicating sex differences in the autoregulatory capacity of the basilar artery in young teens [31] and a significantly lower cerebrovascular reactivity to l-arginine in the posterior circulation in adult males [32].…”

“…To a large extent, PCiS and anterior circulation ischemic stroke (ACiS) share vascular risk factors and stroke mechanisms [1,4]. PCiS has been reported to occur more commonly than ACiS in young patients in whom cervical artery dissection is more frequent [5] and in patients with MELAS and Fabry's disease [6]. Previous studies comparing PCiS and ACiS suffer from heterogeneous sample sizes, diagnostic criteria, imaging methods, and subtype classification.…”