USA TODAY MAGAZINE: Rethinking the Stroke Factor

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It is time to stop thinking of stroke as a disease only of the elderly. A study found that people in the 20 to 54 age range accounted for 18.6% of first strokes in a recent 12-month period—a 5.7% rise in little more than a decade—and average age at stroke occurrence dropped from 71 to 69. Stroke is the fourth-leading cause of death in the U.S., but equally alarming is that stroke is the No. 1 cause of adult disability. Strokes in younger people, in the prime of their productive and wage-earning years, put enormous strains on families and society in a one-two punch: just at the time patients lose their ability to make a living (temporarily or permanently) they are hit with the costs of acute treatment, rehabilitation, and, often, long-term care.

True, stroke is more common in the older population, but new data shows it can occur at any age, and the increase is greatest in the middle-aged and preretirement groups. We do not know all of the reasons for the stroke increase in younger people, but we do know that certain diseases and lifestyle factors—such as diabetes, obesity, high cholesterol, high blood pressure, and smoking—increase stroke risk at any age. There may be dozens of rare causes for the increase, but three are common enough to deserve closer attention: drug abuse, migraine headaches, and brain artery injuries called dissections.

A 2007 study found that using cocaine or methamphetamines increases stroke risk—and the rising abuse of these substances is leading to more strokes among younger people. A recent review of medical literature published in the journal Stroke suggests marijuana use also may be an underrecognized stroke risk factor, leading to shrinkage of the brain’s blood vessels. Moreover, a new case-controlled study presented at the 2013 International Stroke Conference showed a strong link between marijuana smoking and stroke. Of 160 stroke patients with an average age of 45, 16% tested positive for cannabis, compared to 8 percent of a nonstroke control group.

Another concern in recent years is synthetic marijuana, sometimes referred to as “legal weed” and even sold as potpourri in legitimate stores. These substances, which may have different chemical properties in every batch, were linked to 11,406 drug-related emergency department visits in 2010, according to a report by the Substance Abuse and Mental Health Services Administration. The agency said patients were treated for agitation, nausea, vomiting, rapid heartbeat, elevated blood pressure, tremor, seizures, hallucinations, paranoid behavior, and nonresponsiveness.

Stroke-associated substances are not limited to recreational drugs; they also can be found in unexpected places, including herbal and energy drinks, which may contain a variety of amphetamine-like stimulants and large amounts of caffeine. Often marketed as nutritional supplements, which are subject to far less government regulation than foods and drugs—some drinks, especially when consumed quickly and in large amounts, can increase heart rate and blood pressure and make blood more likely to clot.

Herbal supplements and remedies available in health food stores also can have amphetamine-like effects. Natural products such as guarana, ginseng, and gingko can affect heart rate, blood pressure, and blood clotting. For healthy people, and in limited amounts, herbs may be harmless or even beneficial, but people with medical problems and those taking other medications especially should be wary.

Perhaps surprisingly, a 2012 study found an association between daily drinking of soda, even diet soda, and increased stroke risk. The research appears to be sound, although it needs to be substantiated in larger studies, but this seems to be further proof of two things. There is something to be said for moderation in all things, and we still have more to learn about many of the substances we ingest and the impact they have on stroke risk.

Many neurologists have had a longstanding suspicion that migraine headaches increase a patient’s risk of suffering heart disease and stroke, and recent studies seem to be confirming these observations, especially among those who have visual or other sensory disturbances with their migraines. This by no means suggests that everyone who has migraines will have a stroke; risk is increased only slightly. Yet, for reasons unknown, stroke centers are seeing more migraine-related strokes.

Headaches go by different names—such as tension, sinus, and cluster—but any headache that occurs regularly (be it weekly, monthly, or four or five times annually) is a form of migraine, and migraines cause chemical changes in the brain that increase the risk for stroke. They also can cause symptoms that mimic those of stroke, making an on-the-spot diagnosis virtually impossible.

KCBS-TV reporter Serene Branson had the misfortune of broadcasting live from the Grammy Awards in February 2011 when she suffered one of these migraines. Her inability to express her thoughts led to the belief that she was intoxicated or had suffered a stroke, but the ensuing coverage of her experience revealed that she suffered a particularly dangerous form of migraine: complex migraine. Coverage of her story may have enlightened many to the possibility and seriousness of this type of headache.

Headaches as harbingers

Because some migraines can be strong enough to cause arterial narrowing and bring on a stroke, these headaches must be evaluated carefully, diagnosed accurately, and treated aggressively to be sure the arteries remain open. When a headache seems like more than a headache, seek help and let a neurologist decide on next steps.

Arteries have an inner, middle, and outer lining. If a defect or tear occurs in the inner lining, blood can get into this space and cause further damage, leading to blockage of the artery and ischemic stroke or complete rupture of the artery and hemorrhagic (bleeding) stroke.

Most dissections are caused by traumatic injuries to the neck, when the vertebral or carotid arteries are damaged. Among possible explanations for an increase in these cases, I think, are that many baby boomers are hesistant to accept the physical limitations of getting older, imagining themselves to be eternally youthful and able to compete with those in their teens and 20s. For example, I have treated men in their 50s who fell while surfing, skiing, or playing basketball and suffered strokes caused by arterial dissections. With more people remaining active—and maybe not always reasonably active—we are seeing more injuries, dissections, and strokes.

Arterial dissections can occur spontaneously, for no apparent reason, although in some cases there is an underlying connective tissue disorder. These spontaneous dissections are estimated to cause only about two percent of all strokes, but possibly up to 25% of those in people of young and middle age.

The National Stroke Association estimates that 7,000,000 stroke survivors over age 20 are alive today in the U.S., but the needs, experiences, perspectives, and hopes of a 40-year-old with two children and a full-time job are different than those of a retiree in her 80s.

Our stroke center, like several others, offers two ongoing support groups. One is open to all ages; the other focuses on those in the 18 to 55 age range. It started more than five years ago at the request of a patient who suffered a stroke at 26.

If a person in his or her 70s suddenly loses the ability to speak or becomes unbalanced and falls, family and friends likely would suspect the onset of a stroke and call 911, but what if that person is 60 or 40 or 25? No matter the age, if the symptoms look like those of a stroke, the situation is an emergency. Call 911.

The American Stroke Association and the National Stroke Association use the acronym FAST to heighten awareness of commonly seen signs of a stroke: face drooping, arm weakness, speech difficulty—time to call 911.

The five warning signs of stroke include sudden: numbness or weakness of the face, arm, or leg on one side of the body; confusion, trouble speaking or understanding; trouble seeing on one side; severe difficulty walking, dizziness, loss of balance or coordination; and severe headache with no known cause.

It is important to emphasize the words sudden and severe. Any of these symptoms can occur in a mild, fleeting way and not be worrisome, but if onset is sudden and quite severe, it could signal onset of a stroke, which is increasingly described as a “brain attack,” because, like a heart attack, a stroke requires immediate action to improve the odds against disability and death.

The National Stroke Association estimates that two-thirds of stroke survivors have some disability. “Clot-busting” drugs make it possible in some cases to stop a stroke in progress and even reverse damage done, but the crucial element is time. If given within three hours of onset, the drug improves outcomes by about 30%.

Not every hospital or stroke center has the facilities, staff, or resources to provide complete care for every stroke patient, but many hospitals and health authorities are collaborating to establish regional stroke-treatment networks to be sure that even the most complex cases are transferred rapidly to a center with the needed level of care.

Still, no amount of readiness can make a difference unless someone recognizes the symptoms and calls 911.

Patrick D. Lyden is director of the Stroke Program and chair of the Department of Neurology at Cedars-Sinai Medical Center in Los Angeles, California.