Neurology Now:
February-march 2013 - Volume 9 - Issue 1 - p 19–26
doi: 10.1097/01.NNN.0000427282.19003.9c
Features: Young Adult Stroke
Age Is Just a Number: Young adult stroke is one the rise. Here's what you should know
Stephens, Stephani
Illustrations by Brian Stauffer
With another energetic daily workout behind her, Dana
Hokin came back to her home in Scarsdale, NY, at 9:45 a.m., showered,
and then bent down to retrieve her dropped towel. Suddenly, the vision
in her right eye became “squiggly,” then blurry, then totally black. Age
44 at the time, Hokin didn't know exactly what was happening, but she
knew it wasn't good.
“I had always been diligent about doctor visits, and I
was in great shape,” Hokin remembers of Sept. 22, 2011. She called her
husband, Michael, then her mother, Ellen—who suggested it was a detached
retina—and then a nearby retinal specialist, Howard Charles, M.D., at
the Mt. Kisco Medical Group in Rye, NY. However, acute symptoms such as
Hokin's are best treated in an emergency department.
Precious time was passing as Hokin arrived at Dr.
Charles' office around 11 a.m. After an examination, he determined Hokin
had a blockage in one of the small arteries carrying blood to her
retina. The condition—central retinal artery occlusion (CRAO)—is
relatively rare, occurring in less than 3.5 per 100,000 people.
Sometimes referred to as ocular stroke, CRAO can result in severe or
permanent vision loss and increases a person's risk for an ischemic
stroke of the brain, which is also caused by a blocked artery.
Dr. Charles knew that the sooner a person with stroke
gets treatment, the better the outcome. (See box, “Stroke: The Basics.”)
So he arranged for Hokin to be taken to the nearest stroke center, at
St. Luke's Hospital in New York, NY.
Once there, Hokin's team included Johanna T. Fifi, M.D.,
a neuroendovascular surgeon (who specializes in minimally invasive
procedures of the brain and spine), and assistant professor at the
Albert Einstein College of Medicine in Bronx, NY; and Carolyn
Brockington, M.D., director of the Stroke Center at St. Luke's Roosevelt
Hospital Center and Beth Israel Medical Center, both in New York, NY.
At 3 p.m., their patient underwent a three-hour procedure to dissolve
her clot with the drug tissue plasminogen activator (tPA), which is the
most promising treatment approved by the U.S. Food & Drug
Administration (FDA) for an ischemic stroke. It dissolves blood clots,
improving blood flow to prevent further organ or tissue damage when
administered intravenously within a 3- to 4.5-hour window of time (if
given directly into an artery, as in Hokin's case, the window is 8
hours). Although tPA is not FDA-approved for CRAO, Hokin's doctors felt
it was the best treatment in her case.
Catalyst for Change
In 2008, Ronald Stewart, M. D., was one of several
people advocating for designated stroke centers in San Antonio, TX,
where he lives and works. A designated stroke center is a hospital that
specializes in stroke care. Dr. Stewart chaired both the surgery
department at the University of Texas Health Science Center at San
Antonio and the Southwest Texas Regional Advisory Council, which
oversees care for patients with traumatic injuries, heart attacks, and
strokes across 22 south Texas counties. He still holds both positions.
Back in 2008, at yet another meeting held on the topic
of designated stroke centers, Dr. Stewart once quipped, “You know what? I
have atrial fibrillation [the most common cause of irregular heart beat
and a risk factor for stroke]. I could have a stroke and need you guys
someday.”
He did.
And he did.
He was 53 years old and sitting at his home computer on
December 21, 2011, when he experienced a type of ischemic stroke caused
by multiple clots in the brain—in his case, on the left side of his
brain. His arm involuntarily shot straight up as he struggled to make
sense to his daughter Elizabeth. Fortunately, within a matter of
minutes, he was able to tell her he'd had a stroke, needed an aspirin,
and needed to go to the university hospital. She called 911.
By then, thanks in part to his efforts, that facility
had implemented a designated stroke center, as had nine other San
Antonio hospitals. He was treated by the team of his colleague and
friend, Robin L. Brey, M. D., chair of the department of neurology at
the University of Texas Health Science Center, Fellow of the AAN, and
editor-in-chief of Neurology Now. She quickly diagnosed his
stroke and administered tissue plasminogen activator (tPA), which
dissolves blood clots, improving blood flow to prevent further organ or
tissue damage when administered intravenously within a 3 to 4.5-hour
window of time. Having recovered fully, Dr. Stewart is now eager to
share his wisdom.
“Patients who have atrial fibrillation should take an
anticoagulant or blood thinner. I should have been on something more
than aspirin, as my doctors had recommended,” he says somewhat
sheepishly.
“And if you think you're having a stroke, don't say,
‘This will get better,’ because it won't. Call 911 and go to the
hospital, not to a doctor's office or a clinic. Take an ambulance so you
don't waste time in the waiting room—the quicker you get stroke
treatment, the better your chances,” Dr. Stewart says.
“If symptoms include sudden alterations in consciousness
and neurologic function, don't hesitate to think stroke,” says Dr.
Stewart. “Lots of younger people who have periodic atrial fibrillation
may or may not be diagnosed. It's more common than most people believe.”
Dr. Stewart is back to full speed in his career and his
life—and happy to talk, walk, and work again. “As best I can tell, I've
made a complete recovery. I am very blessed and very grateful,” he says.
NUMBERS ON THE RISE
The clot, which remained for more than five hours, destroyed 80 percent of Hokin's vision, leaving 20 percent blurred.
“You're so young to have had a stroke,” Hokin remembers
one doctor telling her. In fact, many well-known people have had strokes
at a relatively young age: actor Kevin Sorbo (see our article on him at
http://bit.ly/osbflE);
actress Sharon Stone; Sen. Mark Kirk (R-Ill.); Beau Biden, son of U. S.
Vice President Joseph Biden; Tedy Bruschi, former linebacker for the
New England Patriots (see our story on Bruschi at http://bit.ly/136pE7P); and singer/songwriter Bret Michaels; to name a few.
Stroke symptoms such as dizziness or headache can be
confusing—mimicking signs of other conditions, including brain tumor,
multiple sclerosis, spinal cord injury, or serious infection. Stroke can
also masquerade as vertigo, alcohol intoxication, inner ear disorder,
or migraine headache. (See box, “Warning Signs of Stroke.”)
One out of seven patients with stroke between the ages
of 16 and 50 was misdiagnosed according to a 2011 study conducted by the
department of neurology and stroke program at Wayne State
University/Detroit Medical Center, according to program director and
study co-author Seemant Chaturvedi, M.D., professor of neurology and
Fellow of both the American Academy of Neurology (AAN) and the American
Heart Association.
“One out of seven is not a trivial number when you
consider that more than 50,000 young people have a stroke each year,”
Dr. Chaturvedi says.
Early use of magnetic resonance imaging (MRI) can
improve diagnostic accuracy in young adults with stroke, as can having a
neurologist see the patient in the emergency department.
HOW YOUNG IS YOUNG?
So just who is a “young adult”? Experts agree it can be a controversial issue.
Dr. Chaturvedi defines the term as between the ages of
18 and 50. “That number has been commonly used in previous studies,” he
says.
Others define the upper limit as between ages 45 or 50
years, according to Aneesh B. Singhal, M.D., of Massachusetts General
Hospital's department of neurology and stroke service. “The vast
majority say age 45, a few say 49, one or two say 55, but 45 is the
standard,” says Dr. Singhal. “It is a ‘moving target,’ an arbitrary
definition that depends upon the research you're doing. We really should
emphasize that stroke can affect people of all ages including newborns,
children, adolescents, young adults, and middle-aged individuals—not
just the old and very old.”
True, nearly three-quarters of all strokes do occur in
people over the age of 65, and stroke risk more than doubles each decade
after the age of 55. But evidence continues to mount that strokes
really don't just occur in the elderly, in spite of what many people
think.
“It's possible that the increases in stroke among the
young result from better detection, due to advances in brain imaging
such as MRI,” says Dr. Singhal. But he also refers to studies such as
the 2012 study from the University of Cincinnati College of Medicine in
Ohio led by Brett M. Kissela, M.D., M.S., and Fellow of the AAN:
According to the study, rates of modifiable stroke risk factors such as
hypertension, diabetes, obesity, and cigarette smoking increased
significantly between 1993 and 2005, as did rates of first stroke, among
patients age 20 to 54.
“The data are particularly relevant given the U.S. and global epidemics of obesity and diabetes,” says Dr. Singhal.
Warning Signs of Stroke
Stroke strikes fast. You should, too. Call 9-1-1 if you experience any of these signs:
* Sudden numbness or weakness of the face, arm or leg, especially on one side of the body
* Sudden confusion, trouble speaking or understanding
* Sudden trouble seeing in one or both eyes
* Sudden trouble walking, dizziness, loss of balance or coordination
* Sudden, severe headache with no known cause
Call 911 immediately if you or someone you are with
shows signs of having a stroke. Do not try to drive yourself to the
hospital.
Stroke can happen with just one of these symptoms, and
the symptoms can vary. In addition, the symptoms can either start slowly
or come on quickly.
STROKE CAUSE AND EFFECT
For stroke in general, doctors determine a cause in
about two-thirds of cases. “The cause of stroke in young adults is much
more ‘wide spectrum,’ with a high frequency of causes that, overall, are
considered uncommon,” says Dr. Singhal.
Dr. Singhal co-authored an October 2012 study that found
newer diagnostic tests—such as CT angiography, genetic studies, and
newer blood tests—can detect the cause in the vast majority of young
adult stroke patients. It also found that vascular risk factors are
common and that early treatment with clot-busting agents can be safe.
The most common collective cause among patients younger
than age 45 is disease of the arteries in the brain, according to Dr.
Singhal. Atherosclerosis is prevalent in approximately 10 percent of
young patients with stroke and can result from high blood pressure, high
cholesterol, smoking, or physical inactivity, he notes.
Younger patients who have diabetes, HIV/AIDS,
tuberculosis, the autoimmune disease lupus, or migraines are also at
increased risk for stroke. Migraine with aura—visual sensory
disturbances that precede or accompany the migraine—increases a woman's
risk of stroke two-fold to three-fold, Dr. Singhal says. The risk is
12-fold to 16-fold higher for women with migraine with aura who also
smoke and take oral contraceptive pills.
Birth control pills have been the subject of much
discussion and research; they remain generally ill-advised for women who
smoke. They can also raise stroke risk for women over 35 and those with
high blood pressure, diabetes, or high cholesterol. Pregnancy also
raises stroke risk for women.
Dr. Singhal offers this advice. “Clinical guidelines
recommend against using oral contraceptives in women who have had a
stroke—which is all about secondary prevention. Most experts agree that
women with migraine should take progesterone-only contraceptives.”
Stroke: The Basics
There are two types of stroke: ischemic and hemorrhagic.
Ischemic stroke is caused by blockage of a blood vessel supplying the
brain. Hemorrhagic stroke is caused by bleeding into or around the
brain.
How common is stroke?
* About 795,000 Americans each year experience a new or
recurrent stroke. On average, a stroke occurs every 40 seconds in the
United States.
* Stroke kills more than 137,000 people a
year—approximately 1 of every 18 deaths. It's the fourth-highest cause
of death in the United States.
* About 40 percent of stroke deaths occur in men, and 60 percent in women.
What are the risk factors for stroke?
Risk factors that can be treated, changed, or controlled
include high blood pressure, cigarette smoking, diabetes, carotid or
other artery disease, peripheral artery disease, atrial fibrillation
(irregular heartbeat), heart failure, sickle cell anemia, high
cholesterol, poor diet, physical inactivity, and obesity.
* Prior stroke, transient ischemic attack (TIA), or
heart attack: The risk of stroke for someone who has already had one is
many times that of a person who has not. A TIA produces stroke-like
symptoms but no lasting damage; it is also a predictor of stroke. And if
you have had a heart attack, you are at higher risk of having a stroke.
* Age: The chance of having a stroke approximately doubles for each decade of life after age 55.
* Sex: Stroke is more common in men than in women. In
most age groups, more men than women will have a stroke in a given year.
However, more than half of total stroke deaths occur in women. At all
ages, more women than men die of stroke. Use of birth control pills and
pregnancy pose special stroke risks for women.
* Race: African-Americans have a much higher risk of
death from a stroke than whites do, partly because African-Americans
have higher risks of high blood pressure, diabetes, and obesity.
* Family history: Stroke risk is greater if a parent,
grandparent, sister, or brother has had a stroke. Rarely, strokes may be
symptoms of genetic disorders like cerebral autosomal dominant
arteriopathy with subcortical infarcts and leukoencephalopathy
(CADASIL).
What treatments are available?
* Prevention: The best treatment for stroke is
prevention. Therapies to prevent a first or recurrent stroke are based
on treating an individual's underlying risk factors for stroke, such as
high blood pressure, atrial fibrillation, and diabetes.
* Acute stroke therapies immediately after a stroke:
These try to stop a stroke while it is happening by quickly dissolving
the blood clot causing an ischemic stroke or by stopping the bleeding of
a hemorrhagic stroke. Medication or drug therapy is the most common
treatment for stroke. The most popular classes of drugs used to prevent
or treat stroke are antithrombotics and thrombolytics.
* Post-stroke rehabilitation: This helps a patient prevent or overcome disabilities that can result from stroke damage.
What research is being done?
The National Institute of Neurological Disorders and Stroke (ninds.nih.gov)
conducts stroke research and clinical trials at its laboratories and
clinics at the National Institutes of Health (NIH) and through grants to
major medical institutions. Some of the topics of current stroke
research include: how stroke risk factors contribute to stroke; how
stroke damages the brain; the genetics of stroke; and ways to help the
brain repair itself after stroke to restore important cognitive
functions. New advances in imaging and rehabilitation have shown that
the brain can compensate for some function lost as a result of stroke.
LOOKING FORWARD
Dana Hokin has relearned necessary daily life skills and
is grateful for the little things. “You don't know how much you can't
handle,” she says, recalling how she felt somewhat “helpless”
immediately after her stroke. The road back to normalcy presents a few
bumps along with new insights, like learning to drive a car again—and
smashing the rear-view window along the way.
“I deal with my vision loss every day,” she says. “But I
have a lifeline to an amazing husband and two wonderful kids and my
friends. ‘Stuff happens’ to everyone, and this is my thing. I'm grateful
it wasn't worse, and I am moving on and not dwelling on my stroke,”
Hokin says.
“Not everybody has a devastating stroke,” says Dr.
Chaturvedi. “A lot of young people have made a good recovery. We are
continually optimistic about the increasing number of excellent
diagnostic tools for stroke.”
“The good news is that some of the possible contributing
factors to these strokes can be modified with lifestyle changes, such
as diet and exercise,” said Dr. Kissela in a prepared statement.
“However, given the increase in stroke among those younger than 55,
younger adults should see a doctor regularly to monitor their overall
health and risk for stroke and heart disease.”
©2013 American Academy of Neurology
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