In most patients with frontotemporal lobe degeneration (FTLD), the degenerative process begins between the ages 45 and 65 years; onset younger than 45 years is relatively rare and considered very early onset FTLD (VEO-FTLD).To delineate the clinical, genetic, and pathological features of VEO-FTLD.A systematic literature review was carried out in PubMed and Embase from inception to September 2021. Patients diagnosed with definite FTLD with onset before age 45 years were included. Patients lacking detailed clinical data or both genetic and neuropathological data were excluded. Phenotypic, genotypic, and pathological data were extracted for further analyses.Data from 110 patients with VEO-FTLD, reported in a cumulative 70 publications, were included. Age of onset was 35.09 ± 7.04 (14-44) years. Sixty-seven patients were reported age at death of 42.12 ± 7.26 (24-58) years, with a disease course lasting 8.13 ± 4.69 (1-20) years. Behavioural variant frontotemporal dementia (104/110, 94.5%) was the most common clinical subtype, often manifesting as disinhibition (81.8%) and apathy (80.9%), and frequently accompanied by a cognitive deficit (90.9%) and parkinsonism (37.3%). Familial aggregate was high (familial vs sporadic, 73/37, 66.4%); most patients carried MAPT gene mutations (72.9% familial, 40% sporadic), followed by C9 (18.8% familial, 10.0% sporadic), TARDBP (2.1% familial), and VCP (2.1% familial). The most common neuropathology subtype was tau (43.5%), followed by ubiquitin-positive (24.6%), FUS (20.3%), and TDP 43 (2.9%).VEO-FTLD may have unique clinical, genetic, and neuropathological markers and should be considered in young patients with psycho-behavioral symptoms.Copyright© Bentham Science Publishers; For any queries, please email at epub@benthamscience.net.