Editor's Note:
Stroke and Aphasia have a new face.
Stroke is a leading cause of disability, cognitive impairment, and death in the United States and accounts for 1.7% of national health expenditures. [1] On average, every 40 seconds, someone in the United States has a stroke; but, it's no longer elderly people 65 and over; according to articles in The Washington Post [2] and the journal Circulation [3]:
Approximately 10 - 15 percent of the nearly 800,000 strokes that Americans suffer each year occur in people younger than 50.
If these estimates are correct, an estimated 80,000 to 120,000 young people yearly may have aphasia as a result of stroke.
A 2012 article from The Lancet [4] shows that "evidence is emerging from the USA that, while the incidence of stroke is falling in elderly people, there is a shift towards an earlier age at stroke onset and that incidence of stroke is rising in young adults. Stroke in young people has an enormous effect on the overall burden of stroke because of greater loss of productivity and higher health-care expenses over time; thus, urgent action is needed to address this alarming trend.
Burden indeed; a recent study [5] found that 12 percent of survivors age 50 and younger failed to recover their independence after 10 years.
> Types of Strokes
The most common type of stroke is a blockage, called an ischemic stroke. It happens when a clot blocks an artery that carries blood to the brain. That type of stroke may be caused by cerebral thrombosis, in a main artery of the brain.
It could also happen if a cerebral embolism, a blockage caused by a blood clot, air bubble or fat globule or embolism, forms in a blood vessel somewhere else in the body and is then carried through the bloodstream and into the brain.
Finally, the cause could also be a blockage in the tiny blood vessels deep within the brain, called lacunar stroke.
Approximately 42% of strokes in young adults are ischemic strokes.
The second type of stroke is a bleed, occurring when a blood vessel bursts, causing a hemorrhage inside the brain, called an hemorrhagic stroke. It may be caused by intracerebral hemorrhaging, when a blood vessel bursts within the brain or a subarachnoid hemorrhage, when a blood vessel on the surface of the brain bleeds into the area between the brain and the skull in subarachnoid space.
Hemorrhagic stroke, the deadliest form that is mainly caused by high blood pressure, is the most common type of stroke in young adults. Hemorrhagic strokes represent 20% of all strokes in the United States and young people account for many of these.
Intracranial hemorrhage accounts for 41% and subarachnoid hemorrhage accounts for 17% of these strokes in young adults.
> Stroke Risk Factors in Young People
A study by Ji et al [5] "shows the contemporary profile of ischemic stroke in young adults admitted to a tertiary stroke center". The study said:
The causes are heterogeneous; however, young adults have a high rate of traditional vascular risk factors. There were high incidence rates of hypertension (20%), diabetes mellitus (11%), dyslipidemia (38%), and smoking (34%). Relevant abnormalities were shown on cerebral angiography in 136 of 203 patients, on cardiac ultrasonography in 100 of 195, on Holter monitoring in 2 of 192; and on hypercoagulable panel in 30 of 189 patients.
Multiple infarcts were observed in 31% and were more prevalent in individuals younger than age 35 years. Relevant arterial lesions were frequently detected in the middle cerebral artery (23%), internal carotid artery (13%), and vertebrobasilar arteries (13%). Cardioembolic stroke occurred in 47% (including 17% with isolated patent foramen ovale), and 11% had undetermined stroke etiology.
The Lancet concurs [4]:
It is a "change in the demographics of causal risk factors for stroke: increasing obesity in . . . young adults caused by sedentary lifestyles and unhealthy diets . . . [translating] into premature vascular disease, including stroke, through raised blood pressure and diabetes.
The journal goes on to state:
According to the National Health and Nutritional Health Survey, prevalence of stroke risk factors has almost doubled in recent years among adults aged 20-54 in the USA: prevalence of diabetes increased from 2% in 1988-94 to 4% in 2005-06; high cholesterol from 11% to 21%; and obesity from 19% to 34%. Increased cigarette smoking and use of recreational drugs, and decreased access to health care among those at highest risk, such as ethnic minorities and poorly educated individuals, might also play a part.
The age factor may also work against young people when they show up in emergency rooms. A recent study from Johns Hopkins University suggests that ER doctors may be up to 30 percent more likely to overlook signs of stroke in women and minorities. And for patients under 45, the odds are much greater than for those who are older. [ 7]
Dr. David Newman-Toker, a neurologist at Johns Hopkins and the study's lead author, used federal health care data and tracked the discharge records and emergency visits of nearly 200,000 stroke patients in more than 1,000 hospitals.
Says Newman-Toker:
Younger people are less likely to have a stroke, but when they have that stroke, they're much more likely to be missed.
Nearly 13 percent of people admitted to the hospital with a stroke diagnosis had visited the emergency room up to 30 days earlier with complaints of headaches and dizziness, which . . . may have indicated that they either were having a stroke with atypical symptoms or were having a minor attack that acted as a precursor to a more severe stroke.
But during the initial visit, these patients either were diagnosed with benign conditions like inner ear infection or migraine, or were sent home with no diagnosis at all.
Roughly a quarter of these patients returned less than 48 hours later in the midst of an obvious stroke.
Sources:
1. AHA/ASA Policy Statement: Forecasting the Future of Stroke in the United States, Stroke.
2013; 44: 2361-2375
2. Heart Disease and Stroke Statistics-2014 Update, Circulation, "Chapter 14 - Stroke", 2014; 129: e28-e292
3. Strokes long on the decline among the elderly are rising among younger adults, Washington Post, June 16, 2014
4. Challenging age-old ideas about stroke, Lancet.com/neurology Vol 11 December 2012
5. Early strokes leave many young adults with long-lasting disability, Science Daily, February 27, 2014
6. Ji, R et al, JAMA Neurol. 2013 Jan;70(1):51-7
7. Emergency Docs More Likely To Miss Signs Of Stroke In The Young, NPR, April 05, 2014
